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A project of Volunteers in Asia
he Human Factor
Contact Special Series No. 3
Edited by: Susan B. Rifkin
Published by:
Medical Commission
World Council of Churches
150 route de Ferney
CH-1211 Geneva 20
Paper copies are $ 2.00.
Available from:
Christian Medical Commission
World Council of Churches
150 route de Ferney
CH-1211 Geneva 20
Reproduced by permission
of the Christian
Reproduction of this microfiche document in any
form is sup lect to the same restrictions
as those
of the original
Christian Medical Commission
JUNE 1980
WwId Council of Churches
150, route de Ferney
1211Geneva 20
Guest Editor: Susan B. Rifkin
CQNTACT Qwcial Series is an occasional publication of the Christian Medical Commission. Each issue
is dbignq
to @her under one cover a collection of articles dealing with a singl? theme. This is the
third of this monograph series.
CONTACT Special Series Number 1 - April 1979
The Principles and Practice of Primary Health Care
CONTACT Special Series Number 2 - June 1979
In Search of Wholeness...Healing and Caring
The price for each number cf the Special Series includes postage:
Sfr. 3.50
El .W
illustmtion : Stuart J. Kingmr WC, Geneva
CONTACT is the periodical bulletin of the Christian Medical Commission, a subunit of the World Council of Churches.
It is published six times a year and WApearsin four langrage versions: English, French, Spanish and Portuguese. Present
circulation is in excess of 15,OM. The papers presented in CONTACT deal with varied aspects of the Christian
communities’ involvement in hrwlth, and seek to report topical, innovative and courageous approaches to the
promotion of health and integrated development.
The editorial committee for CONTACT consists of: Stuart Kingma, Associate Director and Editor, Miriam Reidy,
Editorial Assistant and. Heidi Schweiter, Administrative Assistant The rest of CMC staff also participate actively in
choosing topics for emphasis and the development of materials: Nita Barrow, Director, Eric Ram, Associate Director
(special portofolio:
Family Health), Jeanne Nemec, Secretary for Studies, Trudy Schaefer, Secretary for
and Victor Vaca, Consultant. Rosa Demaurex, Secretary, is responsible for the CONTACT mailing-list.
CONTACTis printed by lmprimerie Arduino, 1224 ChBne-Bougeries/Geneva, Switzerland.
CONTACT is available free of any subscription payment, which is made possible by the contributions of interested
donors. In addition, regular readers who are able to make a small donation in support of printing and mailing costs are
ancouragad to do so.
Certrin back issues are available on requests. A complete liste of these is published regularly and appears in the first
issue of each year in each languafp version.
Articles may be freely reproduced, providing appropriate acknow!edgement is made to: “CONTACT,
bulletin of the Christian Medical Commission of the World Council of Churches, Geneva.”
the bi-monthly
Guest Editor: Susan B. Rifkin
June 1980
CONTACT Special Series is a publication
The Christian Medical Commission
World Council of Churches
Geneva, Switzerland
Printed by lmprimerie Arduino, Geneva
In .both our regular CONTACT publications and in
this Special Series, we are trying to promote the
continuing debate on the basic issues in primary
health care. Long recognized as crucial among these
basic issues, the factor of community particiipation
is still one of the least undentood of them all. It is
crucial because the effective realization of justice in
health care and development cannot take place if
true participation is denied. Self-reliance will never
ChQIwcterize a programme that fails to provide for
participation of the people at all stsges of planning
and implementation. Sustaining commitment and
support for any programme can only em’, ge .’ 117
thoee who believe that the programme is in their
We are pleased, themfore, to present this issue of
CONTACT Special Series devoted to this important
theme. Out Guest Editor for this issue, MS Susan
Rifkin, has gathered an illuminating series of articles
which treat the several levels and dimensions of
participation. The articles emerge out of a wide
variety of ideological positions and experiences. The
opinions expressed must be understood as those of
the authors, and in any given case do not necessarily
tipresent the view of the Christian Medical
Commission or the World Council of Churches.
However, they are presented, both individually and
collectively, as worthy contributions to the dialogue
on these issues.
Once again, we would like to invite your
participation in the continuing dialogue and debate,
and we would be pleawed to hear your comments
and views. Please write to us at the address on the
front cover.
Susan Rifkin, at present, is a researcher on
community health for the Hong Kong Christian
Council and is an associate of the Center for Asian
Studies at the University of Hong Kong Her current
research concerns a study of three communitybesed, church-related health programmes in Southeast Asia, in the Philippines, Indonesia and Hong
Kong. The purpose of the study is to define and
explore issues which concern community health
programmes generally, and to see the problems and
potentials in dealing with these issues by examining
three case studies.
Rior to this present assignment, Ms Rifkin spent
two yean as the health consultant for the Christian
Conference of Asia, where her work carried her
throughout the region looking at church-related
health programmes. MS Rifkin. has
worked as a health education officer for the
Republic of Zambia and was a Research Fellow at
the University of Sussex where she studied the
health care system of the People’s Republic of
China. She has, been a Visiting Fellow at the
Institute of Development Studies at the University
of Sussex and a Consultant to the World Bank.
Her publications include: Health Care in China: an
published by the Christian Medical
Commission and articles in Journal of Development
Studies, Social Science and Medicine and Lancer.
She also occasionally writes for the Far Eastern
Economic Review.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..*........
.. .... .............. . .............. .. .... .. ........ .. .............. ...
Chapter I
An Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Community Participation, A Planner’s Approach
Susan B. Rifkin
PART I Cmmunity
Chapter II
Towards Another Development in Health . . ..*...........................
Giiran Sterky
Chapter Ill
Community Participation, the Heart of Primary Health Care . . . . . . . . . . . . . . . . .
Manzoor Ahmed
.................... ....................
Rural Health Problems in Developing Countries: The Need for a Comprehensive
Community Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Marie-TM&e Feuerstein
Chapter IV
Chapter V
People Power: Community Participation in ,the Planning of Human Settlements
Mary Racelis Hollnsteiner
Chapter VI
Formulating an Alternative Health Care Scheme for India
D. Banerji
Chapter VII
On the Limitations of Community Health Programmes . . . . . . . . . . . . . , . . . . . . . .
Maria das Merces G. Somarriba
Chap&r VIII
Development Campaigns in Rural Tanzania . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Budd Hall
A Prucass . . . . . . . . ..m.............................
PART Ill Community Pmticiprtiun:
. . . . . . . ..s..................
Chapter IX
From Extension Talk to Community Therapy
Andreas Fuglesang
Chapter X
Health Care and Human Dignity
David Werner
PART IV Community Partiiipatiun:
Chapder Xl
An Illustration
. . . ..*..............................
Development of a Community Health Programme
Mary Johnston
About the Contributors
. . . . . . . . . . . ..*...........
These readings originally
appaarf3r.lin tha following journals:
Anothar Development in Health: Introductory
Gom Sterky. &mvlqnntmt
No 1,
1978. UK.
Participation, the Heart of Primary Health
Childmn, No. 42,
care”, Manzoor Ahmed. A&.munt
UNICEF, Geneva, AprilJuna, 1978. Switzerland.
“Rural Health Problems in Developing Countries: The Need
hr a Comprehawhre &mrnunitv Approach”, Marie-ThMsa
FeuusMn. &urrmur&y &w/-t
Joumd, Vol. ll,.No. 1.
1978. UK.
“Formulating an Altnrnative Health Care Schema for India”,
Dr. D. &nerji.
)Ikulb, in As/e, Christian
confmme of Asir. 1977. sinfppore.
RUJ AMarm,
in Rural Tanzania”,
Extansion Talk to Community
Bud Hall.
Fuglasang. Applied Cbmmunicadons in Davaloping Counbies, Dag Hammarskjold Foundation, ;973. Swadan.
‘People Powar : Community Participation in the Planning of
Human Settlements”, Mary Racelis Hollns&iner. Pni/ippibe
Studies and [email protected] ChIdan, No. 49 UNICEF, Geneva,
Octolmr-Decamber, 1977. (Edited Version) Switzerland.
“Some Guastions Concerning Methods of Ledarship”, Mao
Tse Tung; &/wtsd Works of&o
Tm Ttiepiy,Vol. Ill, Foreign
bnguage Press, lm6, Peking, People’s Firgublic of China.
“Development of ‘a Community Health Pqframme”, Mary
Johnston. Contrct, No. 43. Christian Madical Commission.
February 1978. Switzerland.
The editor wishes to thmk Maria das Memos G. Somarriba
and David Warm for their original contributions.
Tha guest editor afso wishes to thank all thr authors and
pu#lshws for waiving the reprint faes in order that the
production costs could be reduced and the volume could be
sold at a lowar pries.
At an intensive four-week health planning seminar
last year, an Indonesian friend came to talk with me
during a tea break. She told me that, while she felt
meny of the ideas presented at the meetings were
indeed interesting and useful, she also felt that their
presentation was very technical and dry. She said,
problem with you in the West is that you
think development is about increased production
rational economic planning. We in the
c&&ping countries know it is about people”.
Her reflections are shared by many who are looking
for ways to rapidly and radically alter the
impover’bhed living conditions in which the majority
of the world’s people still live. Health is one area of
focus for this concern. Adequate health care is still
denied a nmjority of people in the developing world
because the Western/curative/urban-based he&h
care delivery system has proved both inappropriate
and limited for meeting the needs of these people.
In addition, people lack care because health has too
long been seen as the result of medical technology
rather than a response to human endeavour.
In recent years, the human element in development
has been of increasing importance to the United
Nations (UN). In the area of health, the World
Health Organization (WHO) and the United Nations
Children’s Fund (UNICEF) have been instrumental
in focusing this concern through a series of studies
and conferenars and their evolving concept of
“Prinmry Health Care”. A key element in this new
view of health care is community participation, in
which thoa who =e affected by health policy take
pert in forrmlating that policy.
Thir new area for examination and action community participation in health - still lacks a
significant body of literature. While some case
studies have been written about the personal
experiences of the authors, few have been able to
abetract from specific to general issues in pro~rnme planning. There articles that are. the most
comprehensive and analytical are often singularly
difficult to obtain.
This book of readings is a beginning to correcting
the deficiency in this area. It does not seek to
provide the answers to how to plan a communitybased health programme. Instead, it seeks to
abstract, delineate, clarify and classify some of the
basic questions. In bringing together some of the
most well thought out and provocative essays in one
volume, it allows for comparison of issues in
different ccuntries and for an identification of areas
of concern common to all programmes. Hopefully,
it will challenge planners, be they government
off!cials, medical professionals or community
workers, to look at their assumptions about
community health and to apply revised ideas to
their own programmes.
The selections in this volume are all written by
people who have lived and worked for a number of
years in the developing world. Several are nationals
of the countries about which they write. Reflecting
on health care as a part of the socioeconomiccultural environment rather than solely as the
delivery of a scientific and modem service, these
essays probe the various dimensions of involving the
community in taking responsibility for its own
health and highlight the necessity of emphasizing,
building and protecting the human element in
development programmes. This volume does not
deal with the best known component of communitybased health pmgrammes: the community health
worker. This is a subject of a separate volume. Nor
does it contain an extensive bibliography, due to
both the lack of information on this subject and the
difficulty for most readers in obtaining many of the
This book was compiled as one part of a study
which I am undertaking for the Hong Kong
Christian Council on community-based health care
programmes in Southeast Asia. The study is funded
by Bread for the World of the Diakopische
Deutschland. Funds were also contributed by the
Department of Social Work at the Hong Kong
I am most thankful to a number of people for their
assistance. David Morley and Huw Jones encouraged
ma to undertake this volume. The Health Group at
the Institute
of Development Studies of the
University of Sussex provided much intellectual
stimulus during my stay there in the summer of
1978. I especially owe thanks to Alastair White and
Alanagh Raikes for our riever-ending discussions
about community participation in health. In Hong
Kong, Margret Carter and Mona Lo helped me to
think out various issues. John Anderson, Paul IV::.,rcis
and R. Maru patiently read and commentet! c3n
many of the drafts. And I particularly owe thanks to
Jerry Stromberg in Geneva who gave me advice and
insight to help with this work.
Susan 8. Rifkin
Hong Kong
March, 1979
Susan B. Rifkin
“In the past few years, WI?have seen a flowering of new conctpfions of the development process.
Perhaps the most far-maching is tie accepmnce by ma ,. # count&s and internadonal
of the importance of the human fmtor - as distinct from rhe purely physical or material. ” Henry R.
bbouissa, Executive Director, United Nations Children’s Fund (as quoted in Assignment Children
no. 42, UNICEF, Geneva, April-June, 1979)
In recent years, there has been evidence to suggest
that, particularly in the developing nations, health
and medical services have not achieved the
remarkable improvement for the majority of the
people that they did in the industrial nations in the
late 19th and early 20th century.1 This fact has led
to the obsenration that: “In the absence of dramatic
in medical science, the greatest
potential for improving health is through changes in
what people do and do not do to and for
For this reason, the idea of
community participation has created a great deal of
interest among both planners and field workers
health care activities. Community
participation is seen by many as the key to rapid
and radical health improvements for the poor and
the majority of the world’s people.
one hundred years. Because scientists discovered
how to control and cure disease with penicillin,
and sterile techniques, they also
defined development in health care. The result was
that not only the curative as well as preventive and
practices found their roots in the
clinical laboratories, but also the values and ethos of
the modern medical cu!ture reflected Western
scientific beliefs. Priority was placed on complicated
scientific research and specialized clinical education,
mgardless of cost. This meant the growth of the
importance of institutional,
individual care, the
of the “bio-science”
aspect of
medical education and large allocations for sophisticated medical technologies, teaching hospitals for
research and training and increasing emphasis on
scientific progress.
A major reason for the emphasis c~l”rcommunity
participation in health care is a new understanding
of the concept of health. The traditional Webster
from physical
disease or pain”, has virtually been replaced by the
World Health Organization’s (WHO) definition, “the
state of complete physical, mental and social
well-being of the individual”.
This more positive
concept has emerged as those who are involved with,
and responsible for, health care delivery systems sea
health as being more concerned with people and less
concerned with medical science and its concommitant technology. A brief review of this changing
focus helps us to understand the relationship of
community participation to health.
A change in this narrow medical focus took place in
England in the 1830’s with the publication of the
Reform Acts. Recognizing that disease could be
reduced by the introduction
of public health
measures such as good sanitation, and clean water
supplies, the government enacted laws which
provided some measure of prevention and some
concern for large groups of people rather than
strictly clinical, curative, individual work. Eventually, an argument was accepted that scientific
medicine should not make the division between
prevention and cure and the individual and the
However, the preventive, community
aspects of health still remained in the hands of the
medical professionals who regarded these aspects as
part of a medical delivery system - a system which
was fundamentally
based on the ability to cure
Tine view that health was the absence of disease,
which could be realized through the delivery of
medical services, emerged as a dominant idea in the
mid-nineteenth century. This view was due in great
part to the remarkable scientific achievements in
clinical medicine of that period and of the following
The concentration
of health concerns in a
highly-trained scientific group meant that this group
continued to dominate views about health in both
practical and policy terms. Their orientation often
defined national governments’ ideas about national
health policy. This situation had two rather serious
cansequences. The first was that, often, the national
policy reflected the interest of the medical
profession rather than the needs of the majority of
the country’s
New hospitals, for
instance, took precedence over expanded public
health activities. The rural poor and the urban
shanty dwellers, especially in the developing
countries, often were only spectators of new
medical and health improvements. Secondly, the
medical profession maintained a monopoly on
knowledge about medicine, health and the human
body. It created a mystique around people who had
been trained in, and wrtified by, formal medical
institutions. Thus, not only were the poor deprived
of health resources, they also were denied the
opportunity to learn to use what few resources they
might have in their own communities.3
Professor Rex Fendall, Professor of Tropical
Community Health at Liverpool School of Tropical
Medicine has stated:
“If I were to compose an epitaph on medecine
through the 20th century, it would read:
in its discoveries, superb in its
technological breakthroughs, but woe fts/ly inept
in its application to those most in need. Medicine
will be judged not on its vast and rapid
of knowledge per se# but on its
trusteeship of that know/edge. We are now
eqxrienced, and all that remains is the problem
01 trans!ating what is common knowleo’@ and
routine medicine, and hence practice, to the other
tvw-thirds of the world. The implementation hap
must be closed.‘*4
Fendall’s words reflect the fact that an era of
scientific medicine which realized the potential of
cot;-%4 brnd eradication of many of the world’s most
&,sst-J:ing diseases by the mid-29th century still :x: produwd a radical improvement in the
!lw!th cf the majority of the world’s population.
Th;; Western scientific approach to health could not
direct people’s attitudes towards, and beliefs about,
disease. It had, in reality, produwd a view of health
and a system of health wre delivery which was
acceptable and available to a minority of people and
often only to those who had financial resou es to
afford doctors, drugs and a healthy environme: x t.
Fendall’s observation was one Which has wused
health planners a great deal of wnwrn over the past
twenty years. One might argue that it was Gunnar
Myrdal’s Asian Drama 5 that was a catalyst for
planners, both
in and outside the medical
profession, to begin to turn the tide of health and
medical priorities from individual, curative, clinical
expenditures to programmes which would affect
large numbers of people. As an economist, Myrdal
argued that health was not a “bottomless pit” into
which a benign government poured health care
resources as a gesture of wnwrn for its people.
Rather, he said that health was an “investment in
man” which, if improved, could add to the
productive capacity of a nation because it wouid
increase man-hours available for work. This
argument not only dramatically
questioned the
rationale of existing health and medical policy but
also brought the policy into the fast-growing
“development debate”.
The last fifteen years has produced a body of
the role of health in
It is an area to ; vast even to
sufficiently summarize in this short essay. Suffice it
to say that the growth of general development
theory which included ideas about the priorities of
investment in urban or rural areas, to agricultural or
and capital- or labourintensive investment
strategies, influenced
changing definition of health. In practical terms, one
result was that many doctors who had experience
in developing countries began to question the
wisdom of existing health care allocations in these
countries.7 They argued that the existing policies
which supported a capital-intensive
medical care
system with its large teaching hospitals, its advanced
medical technologies and research and its preoccupation with training fully-qualified
doctors, were both
too expensive and too limited to improve the health
of the majority of the people. Armed with the
support of soma members of the medical field,
economic. planners began to look at the basis of all
health care ajlowtion
of resources in the Third
World.8 Emerging from the work of these people
was sufficient experience and analysis, if not to
introduce the community potential in health, at
least to question the existing health and medical
In the 1966’s, those concerned with health care also
became increasingly concerned about who received
health resources. Evidence was produced to show
that most resources for health and medicine in the
developing countries were going to large urban
curative medical institutions where the majority of a
nation’s doctors served, making them available, in
the absence of national health insurance schemes,
only to the wealthy. In addition, the data showed
that the serious health problems were among the
rural poor, i.e., the majority of the population,
whose priority health problems could be met by
preventive services delivered by paramediwls at a
health wntre. James McGilvray, then Director of the
Christian Medical Commission (CMC) of the World
Council of Churches (WCC), in his speech to the
American Medical Association (AMA) in 1969 very
vwll summed up the thinking about health and
medicine in the decade of the 1960’s. The problems
were, McGilvray said:9
1. the high cost of medical treatment in relation to
the amount of existing resources and the lack of
of this treatment to most of the
2. the limited effectiveness of .ihe highly- and
expensively-trained doctor to d&II with the most
prevalent diseases among the majority of poor
rural people;
3. the dilemma of having knowledge about how to
control and treat disease and having little success
in transferring
that knowledge to radically
improve the health status of the masses; and
4. the competition in resource and time allocations
between individual, clinical care, and community
health care.
This concern, by the early 1970’s, led to the search
for solutions. Major efforts were made to identify
health care systems where health
resources were being used to respond to the needs of
the majority of the people. For a number of
historical and political reasons, one area of this
research focused on health care In the People’s
Republic of China. With the general relaxing of the
strict isolationist policies of the Cultural Revolution,
China invited several groups of prominent ++.Xists
to visit. Those who went as members ’ :;ledical
delegations conZrmed reports of the impressive
advancements China had made in the areas of
control of communicable diseases, in decentralization of health care units, in use of paramedics and
village people who had no formal medical education
and in mobilization of its 800 million people to
engage in health activities.10 Many began to argue
that China had much to teach the world about good
health care delivery.
The Chinese experience emphasized two aspects of
health care which now moved into the forefront of
current thinking. One was that health care was not,
circles, an
as previously argued in influential
apolitical entity subject only to change by scientific
advances. It was a reflection of existing social,
political and economic conditions. Secondly, health
improvement did not depend solely on science and
professionals. Great changes could be brought about
by mobilizing people to take part in health care
activities. This fact was supported by evidence that,
by 1956, China had virtually eradiceted smallpox
and cholera and had drastically reduced typhoid,
typhus, scarlet fever and diphtheria. This was at a
time when the nation was recovering from civil war
and was virtually depleted of resources TV build
more hospitals or dramatically increase its 10,000
Western-trained doctors.1 1
Another source of experiences in alternative health
care programmes were the small voluntary-agencies’
pilot programmes in various poor communities in
Asia, Africa and Latin America. These programmes
were usually begun by a doctor or nurse, often
Christian, who early discovered that health services
were not making an impact on improving the
health of the community.
Learning through
experience that food, clothing and housing were
seen by the people as priorities over health needs,
these health professionals began to develop programmes where health services were but one
element, though possibly the entry point, in a
number of community development programmes
which included agriculture, education and handicraft work. These experiences confirmed the link
between poverty and poor health, and the need to
tackle the whole range of development problems
and not just the lack of medical services. They also
confirmed the fact that getting communities involved
in health and health-related activities could radically
and rapidly improve the health status of the
people. l2
These experiences began to focus on a heretofore
neglected aspect of health - the potential and
necessity of having people in local communities
define and act upon their own health needs. The UN
concern did not suggest that people had never been
involved in their own health care. Each src%iety has
always had a history of involvement in traditional
cures and approaches. What the UN did was to
clearly articulate the necessity of recognizing this
involvement. As early as 1973, a WHO Executive
Board study emphasized the need to find ways of
more systematically developing people’s participation in their own health care. This document stated
in part:
‘L the health services must really be accepted by
the persons they serve. It is not difficult
understand why health services have developed as
a system imposed upon populations - something
that comes in to a town or village from the
outside. Medical literature and project proposals
are filled with terms such as ‘acceptors’, ‘refusal
fan :hes’, ‘under-utilization ‘,
rates ‘, ‘problem
which show clear.‘, [hat the problem is seen as a
failure on the /.Ri t of the people, rather than as a
failure of the health services. What is necessary
now is to solicit community identification with,
and participation in, the development of health
apservices. This will
proaches. “13
This recommendation
was followed
by further
studies which considered in some detail these
recommendations. Among them were the study on
Approaches to Meeting Basic Health
Needs in Developing Countries” (19751, the book
edited by K. Newell, Health by the People (1975)
Involvement in
and the study of “Community
Primary Health Care” (1977).1 4 One result of these
studies was the evolution of a concept of Primary
Health Care (PHC) which is defined by the UN as
“essential health care based on appropriate and
acceptable methods and technology made universally accessible to individuals and families in the
3. medical professionals are not the only people
capable of giving medical advice and treatment;
4. health cannot be isolated from other developmert
policies and agencies;
5. the most sophisticated techno!-.r;y
provide the best car.
does not
6. the doctor/patient
ratio doe:* rrc)t necessarily
indicate the qua;i.:y of care avaiiable; anI<
7. decentralized h&lth planning and institu?,ons are
better able to respond to loca! heale? C;roblems.tG
Today, health is no longer defined as “mere absence
of disease”, made possible by medical science and
medical professionals. It is, in addition, increasingly
being seen as a human right, a part of the
socioeconomic development of a country, and a
reflection of political will. It is less about scientific
advances than it is about people’s needs. In other
words, it is a human condition’ 7 which cannot be
changed solely by the provision of services. Its
improvement also becomes the responsibility
individuals, communities and governments.
Two nmly-trained
in the community
of Pihd,
50 km from Quito, Ecuador, hok4 a dinic Orion for villyrrs.
community through their full participation and at a
cost that the community and country can afford to
maintain in the spirit of self-eliance”.tg
PHC has explicitly
challenged many of the
fundamental concepts of health and medical care
which have dominated health policy for the past
150 years. So that constituent
members could
confront this new challenge, WHO and UNICEF
convened a conference in September, 1978 at AlmaAta, USSR.15 The conference documents detail the
principles which must be considered to establish
PHC in order to provide, in the words of WHO,
“health care for all by the year 2000”. Among these
principles are:
1. health care is political;
2. Western medical care is not the only efficacious
type of health care;
One direct result of this new understanding of
health is the increasing interest in the concept of
community participation. Arguments for community
participation in health are many and varied. The
first and perhaps the strongest is that, in most
health resources are scarce and
community inputs, fcr Instance community health
workers, are needed to increase resources at minimal
cost. A second argument suggests that health
resources are better mobilized and utilized v&en the
community helps to formulate its own health plans.
A third position is that community participation is a
key to mobilization of community resources and
a means of educating the community to accept
health goals established by the medical profession. A
fourth position sees community participation as a
process which has as its aim to question and redefine
health goals with the view of having health policy
defermined by the community
itself.1 8 These
views raise the question of whether
community participation in health care is a means or
an end in itself.1 g They also point to the fact that
the role of community participation in planning is
not an easy one to define. To be able to assess its
potentials and problems, it is perhaps best to make
some observations about the nature of community
The first observation we can make is that, to
consider community participation, it is necessary to
consider the nature of “community”.
A dictionary
definition of community which says it is “a body of
people having common organization or interest, or
living in the same place under the same laws” might
be acceptable for a theoretical view of community
However, in terms of policy and
programmes, those with experience recognize that,
in reality, communities consist of various social,
political and economic groups. These groups can
have different cultural backgrounds and different
values. Often they do not share the same goals and
earna objectives at the same time.
These elements of the diversity of communities in
community participation
efforts have been documented from the experiences of the 1950’s and
1980’s. The community development movement of
this period sought ways of encouraging people to
improve their own lives by relying on their own
initiatives and on their own resources. Using
agriculture in many cases as the focal point, these
were disappointing.
programmes’ achievements
Their failure resulted from, among other things,
conflicting interests within certain communities, the
of the programmes at governmental level, problems with creating new structures
to support these programmes and the unclearlydefined duties of government officials who had to
carry out the programmes in mainly rural
communities. The lessons from this period am worth
studying for those who are now engaged in
community health programmes.
Another important observation is that community
is essentially a political concept. In
making this observation, we can note, firstly, that
the way a community “participates” depends on the
system. A major factor is
the type of system which rules the nation. There is a
basic difference in the organization and objectives of
communities in socialist systems like China and
Cuba from those in non-socialist, capitalist societies.
In the former, the collectives are the basic units of
production and, therefore, the community shares
basic economic objectives. It is essential that
wmmune members participate not only in community work but also in decisions about how the
work will be carried out In the latter, where there is
a high incentive for individual production, objectives
are often shared when people see actual short-term
individual gains. Thus, wnsensus on many activities
might be difficult to obtain.
In countries where there has not been an attempt at
the national level to restructure the society, other
of participation
are the existing
cultural values and social structures. In countries
under the colonial
influence of the Western
democracies, for instance, the idea of participation
often means one man, one vote. However, in many
rural villages where this belief has had little
influence, the agreement of the village chief
represents the agreement of the entire community.
In developing ideas about community
participation, it is necessary to examine the existing
traditions and the structures which support these
traditions. Short of social revolution in which these
structures are totally destroyed, it will be necessary
to take account of, modify and/or change them in
order to make participation viable.
Further, we should understand that participation is
essentially a concept which means that the
community, rather than the government or outside
professionals, has control over health resources and
has the power to decide how these resources will be
used. This highlights
the distinction
and “contribution”.
The former means control by the community. The
latter means that people outside the community,
most often the government, create activities and
provide resources for these activities in which
community people are encouraged to join but over
which they have virtually no control. In commenting on this aspect, Kenneth Newell, former Director
of the Division of Strengthening of Health Services,
WHO, states that it is not enough for people to enter
a partnership with those who have control over the
existing health system, but that the people will have
to ‘I... take the system over as a supporting segment
of their own health concerns or (if this is not
possible) to design a new one”.*0 This call for, in
WHO’s terminology, “health by the people” plainly
spells out the political
nature of community
With these observations in mind, and on the basis of
the experiences of those who have been working in
health programmes, of which
some of the more interesting are compiled in this
book, it is possible to make some observations about
community participation
in health care planning.
What is most important to note is that community
participation cannot be considered a component of
a health care delivery system. It is not something
which can be compartmentalized,
confined to a
series of inputs or costed out. Rather, in terms of
health planning, it must be seen as a strategy and a
process. 8y strategy is meant that community
participation is the context in which a heblth care
programme develops. Because this context confronts
the traditional view that health can be delivered and
acknowledges that health is a human condition
which everyone - the individual, the community,
the government and not only the professionals acts upon, the goal of having the community take
for its own health care must be
carefully developed and supported. A community
strategy is one which can be
characterized in some of the following ways.
It emphasizes people rather than technology.
Traditional health olanning has sought to spread
Western medicine and its concommitant technology
as the basis of health: care deliven/. As we have
noted, this policy has not necessarily improved
health status or health situations, particularly in
rural areas. A community
recognizes the limits of modern technology and
instead emphasizes ways in which communities
might be motivated to change bad health behaviour
and improve their living conditions. The emphasis
on people stresses their ability to choose to improve
their conditions rather than their passive acceptance
of either government or voluntary-agency handouts.
It emphasizes community motivation rather than
service coverage. It recognizes that health services
are often under-utilized and/or utilized improperly
because people have little or no incentive to
maximize the services that are provided. A prime
task of a community participation strategy is to help
the community understand what health care services
can and cannot provide and to utilize the scarce
health care resources for the maximum benefit.
It emphasizes a bottom-up rather than a top-down
approach to health planning. In most health policy
planning, the government and/or voluntary-agency
officials are the ones who define the programme and
give the directives
to the community.
community which receives the programme is rarely
involved in the planning and, therefore, is given little
incentive or commitment
to implement
decisions. Service deliven/ reflects the thinking of
bureaucrats and/or professionals rather than the
needs of those who get the service. Top-down, and
planning from the centre, from which most of the
resources are allocated, does little to encourage good
use of resources and of’ten does much to create
blocks to improving the health of the community, A
community participation strategy is one in which
outside planners work with community leaders to
develop services and communication links which are
responsive to community
needs. The outside
planners serve as a resource base for community
Community participation is also a process. In this
context, process means the various ways in which
people in communities first recognize, and slowly
begin to act upon, their own health problems. A
first step in this process is to enable community
leaders and, eventually,
all members of the
community, to begin to understand that health and
health services should not be equated, and thus that
the community should not rely solely upon the
medical profession for health improvements. Activities which aid this process may include the
formation of health committees and the selection
of, and responsibility
for, community
workers. This process develops in different ways, at
different times in each different community. Some
key features of this process are as follows.
The process emphasizes flexibility rather than rigid
It is a process whereby the policies
which are formulated as much as possible allow local
officials and local people to meet local needs and
encouraw programmes which reflect solutions to
problems that are peculiar to the specific area. This
process, liowever, operates under constraints in the
government different to those under which it
operates in the voluntary sector. For a national
government which must appear to be distributing
resources in a fair and logicai manner, programmes
with community participation must represent some
kind of replicability. The process, therefm, must be
designed to follow general guidelines while maintaining the ability to meet local requirements. This
need argues for government policies which promote
decentralization for decision making.
In programmes developed by voluntary agencies, in
the actual development of the process, it is easier to
ensure flexibility.
These programmes usually have
responsibility for the health care of a relatively small
area. In addition, they often have access to sums of
money from overseas donors which allows much
latitude to including experiments in the programme.
Even in programmes where self-reliance is a goal,
there is the flexibility to experiment because of the
lack of financial problems. However, the voluntary
agencies also operate under some restraints. A major
one is that most governments insist on some type of
If the programme does
not accept government relationships, then its area of
operations can be severely restricted. If it does,
government often attempts to impose its objective
of replicability.
Despite the barriers in both the
government and the voluntary sectors, flexibility is a
mainstay of the process of community participation.
The process begins at the policy level. This means
that those who are committed to implement a
community participation strategy should be able to
give it support at either the government and/or
level, where decisions for progtdmming are made. In addition, this process must
involve, and have the commitment of, those who
have the responsibility to initiate health programmes
with community participation. Because there is little
experience in developing community participation
strategies, the process must start with the planners.
Firstly, it must help planners examine this new
approach to health can?, to criticize and revamp the
existing planning system and to define the specific
steps which might be taken to begin to get the
community involved. Because most present planning
systems are hierarchical in nature and are not given
to encourage participation
of lower levels of
personnel, many planners have no experience in
their changing role in decision making. For this
reason, the initial step in the process must help
planners realize the participation potential of those
who are at the lower level in the hierarchy and help
them to free themselves from the traditional
relationships with their own staff, other officials and
with the community.
Finally, the process must be seen in terms of
longrange goals rather than short-term achievements. It is often necessary to sacrifice what might
seem a radical improvement in health status, for a
period of education in which people unfamiliar with
medical terminology and technology may learn to
put these ideas into their own context. All too
often, campaigns for vaccinations, for instanoe, get
high results when first introduced.
However, if
second or third injections are needed, the number of
people who reappear is very much reduced. Time is
necessary for communities, particularly rural communities, to internalize unfamiliar ideas. If the
process moves too quickly and does not become
part of the new conceptualization
of community
people, then it is questionable whether improvement
in health status, let alone community participation,
has really materialized.
The readings in this volume explore in some detail
the issues in the strategy and process of (what is
now accepted terminology) community-based health
programmes. Based on the long experience of the
various authors, these essays delineate potentials and
problems in this new approach to realizing health
for the majority of the world’s people. Although
they reflect views of people from different
backgrounds, cultures and countries, each essay
contains two important points of reference. The
first is that large-scale improvements in health will
come as a result of actions by the people. The
acond is that these improvements must, therefore,
take people rather than technology as the focus of
planning activities. The challenge for development
planners today is essentially how to allow the
human factor to realize its potential. These essays,
will provide a deeper understanding
about how this challenge can be met.
1975; also Shahid Akhtar and Francis Delaney, (eds.)
Rural Health Care and Health Manpower
Training, vol. I, II, III, IDRC, Canada, 1975, 1976,
7. Maurice
(ed.) Medical
Care in Developing
Countries, Oxford University Press, Nairobi, 1966; John
Health and the Developing
World, Cornell
University Press, Ithaca. 1969.
8. Brian Abel-Smith,
An International
Study of Health
and its Relevance for Health Planning,
WHO, Geneva, 1967; Oscar Gish “Health Planning in
Developing Countries, Journal of Development Studies,
vol. 6, no. 4, 1970.
9. James McGilvray, “The Delivery of Health Services in
Health”, Speech presented to the American Medical
International Health, Chicago, May 22, 1969.
10. Shahid Akhtar,
(ed.) Health Care in the People’s
Republic of China : A Bibliography
with Abstracts
I DAC, Canada, 1975.
11. For the sources of these statistics, see Health Cae in
China, Christian Medical Commission,
Geneva, 1974.
(Out of print)
12. For a variety of these case studies, see CONTACT, a
publication of the Christian Medical Commission, Geneva.
13. V. Djukanovic and E.P. Mach, (eds.) “Organization Studv
Health Services”, Official R~ords of the World Health
Orsanization no. 298, Geneva. 1973.
A joint study on altarnative approaches
to meeting
basic health nczds of populations
countries, Geneva. 1975; Kenneth Newell,
(ed.) Hei&
by &e People, World Health Organization,
Joint Committee on
Geneva, , 1975. UNICEF/WHO
in Primary
Health Policy, “Community
Health Care; A Study of the Process of Community
Motivation and Continued Participation”,
JCPIIUNICEFWH0/77.2., 1977.
Final Report of International
Confereme on Primary Health Care, Alma&a.
11 September,
I. For a study review of the situation, sae Health Sector
Policy Paper, World Bank, Washington, 1975.
2. “Health Care and the US Economic System”, AM/bank
Fund Quarterly,
v.59, no. 2, April, 1972,
p. 22% as quoted in Community
[email protected],
Book 1,
General ComwZs, Health Commission of NSW, Austraha, June, 1977.
Ivan lllich, 77re Limitsof Medicine, Medi& Nemesis: The
of Health, Marion Boyars, London, 1976.
4. Alexander Dorozyuski,
Cam&, 1975.
and Healers, IDRC, p. 8,
5. Gunnar Myrdal
and Seith King, Asian Drama, An
into the Poverty of Nations, Vintage Books,
New York, 1972.
6. For bibliographies on this literature, see Bibliography on
Health Planning in Developing Countries, IDS, Sussex,
16. Ibid.; Also see Primary Haalth Care, A Joint Report by
the Director-General
of the World Health Organization
and the Executive
Director of the United Nations
Children’s Fund, Geneva. 1978.
17. “Another
rogue, 1978: 1 p. 73.
in Health”,
18. These positions were articulated bv Jerry Stromberg of
the Division of Strengthening of Health Services, WHO, in
private correspondence, September 7, 1979.
19. The question of means and ends has been discussed in a
paper which I presented to the International Sociological
in Uppsala, Sweden, in August, 1978.
Entitled “From Community HEALTH to COMMUNITY
Health: An Interpretive Studv of Community Participation in Community
Health Programmes from Case
Studier in Asia”, (unpublished). These ideas are the basis
of a study in which I am now engaged.
20. Keuneth
tember, 1977.
In the theoretical debate about community
participation in health, two distinct views have
emerged. One, which reflects the traditional view of
health planners, is that community participation is a
means by which to deliver better health services.
Th 1 other is that community participation is a
means by which to change the existing social,
political and economic structures that presently
deny accessof the poor to health care.
Both views share a number of common points.
Firstly, they both believe that health services and
opportunities for health improvement should be
available to all members of society but, at this time
in history, especially to the poorest members.
Secondly, they both accept the idea that the people
who benefit from health care must take an active
part in planning that care. Thirdly, they acknowlm
that plans for improved services and health
opportunities nmrst not only be supported by the
national government but also must have contributions of local resources at the local level to make
health plans adaptable to community needs.
Fourthly, they accept that health plans must also
reflect the ability of the government and the
communities to support programmer, and must not
rely on technologies or activities which are neither
appropriate to local conditions nor possible to
support from indigenous resources. Finally, they
agee that community participation is not an end in
itself but a means to improve the entire life
circumstances which, at present, are unacceptable
for the majority of people in the Third World.
The two views, however, diverge in various respects,
for example, on the mans by which health can be
improved. The first approach is based on the belief
that the health of the community can be improved
if health budwts are increased, the existing health
system is extended and the community is
encouraged to participate in health activities. The
second approach argues that none of the above
activities will have a noticeable effect on the health
of the majority of the people without change in the
social, political and economic structures which, at
present, keep most people in most developing
countries in a state of poor health.
Secondly, they differ in objectives. A major
objective of the first approach is to find ways of
providing health services to those who have little or
no access to these senrices at present. A major
objective of the second is to begin a community
building process whereby the potential capacity of
the local population to contribute to their own
health improvements may be tapped.
Finally, it can be said that the first approach is a
community development approach which focuses on
providing assistance to help the community improve
their standard of living. The second approach
emphasizes the need to recognize and confront the
political process whereby the poor can grasp the
power to ensure that the community can secure and
maintain control over the resources to bring about
these improvements.
G&an .Sterky, in the following article, develops the
argument which considers community participation
as a means by which health can be used to change
existing structures which deny equality to the poor.
In confronting the traditional view of community
participation as a component of health care delivery,
he challenges the dominant role of the doctor in
health care decision making and argues that power
must rest in the people who benefit, or, at present,
don’t benefit, from medical and health services. He
analyzes health in terms of the Dag Hammerskjold
Foundation’s “Another Development” and raises
some fundamental questions which must be
explored if health, in its new context of a right and
a human condition, is to have real meaning.
Sterky’s article delineates some basic issues whicR
Manzoor Ahmed explores in his piece on com9
in Primary
Health Care
(Chapter I II). Recognizing that the reality in most
developing countries is that existing structures are
not likely to rapidly change, he tackles the problem
of how to modify the existing system to work
towarcil the “health by the people” objective.
Ahmed has identified areas of concern common to
all community participation programmes regardless
of country, culture and values. His piece gives some
general but very practical ideas about how to
begin a strategy and a process to bring the human
factor into health care.
Giiran Sterky
“Another Development” is totally people-centred.
As defined and elaborated in the 1975 Dag
Hammankjold Report (What Now), it means that
Another Development is:
- being geared to the satisfaction of
the individual’s needs, both material and non-material.
- stemming from the heart of each
society, which defines in sovereignty its values and
the vision of its future.
- relying on the strength and resources
of the society which pursues it, rooted at the local
level in the practice of each community.
resources in
sound - utilizing rationally available
a harmonious
Based on sttuctuml
- originating in
the realization of the conditions for self-ma
ment and participation in decision making by al2
These general statements are not meant ti, provide
specific information on which action cap @&%ased,
but rather to serve as guidelines. The qu&ion now
is: how can we make Another DE relopment
In characterizing the need-oriented nature of
Another Development it should be emphasized that,
though human needs are both material and
non-material, the basic needs of food, habitat,
health and education should be satisfied on a
priority basis. But - whether in food, habitat,
health or education - it is not the absolute scarcity
of resources which explains the sub-satisfaction of
needs; it is rather the distribution of resources, since
traditional mechanisms fostering inequality have
been aggravated by the indiscriminate imitation of
the economic growth model. This poses the problem
and shows the necessity of structural change.
Having accepted the prirrmq of the satisfaction of
mm’s needd in implementing Another Development,
one is led to recognize the importance of finding a
way to measure the quality of human life. We can
take purposeful action only on specific information:
how much is too little, how much is enough and
how much is too much? Where is the floor, and
where is the ceiling?
Another Development rnsy already be at the
crm-roads: wig it just amplify the rhetoric of
current social-development planning or will it
become operational and change and intensify the
dewlcpment process?
Maybe this is the challenge, and it is an exceedingly
tough one. After 25 years of developmental
activities by the United Nations’ multiple agencies,
with so many plans of action, programmes,
strategies and declarations, the painful fact remains
that a satisfactory range of development indicators
still does not exist; and those which do exist are
largely without relevance to policies and practices.
The so-called social indicators have always received
only cursory treatment in the shadow of economics.
The system has thereby not promoted, but
distorted, our perceptions of the very nature of
development and has left nations and communities
without the necessary tools to .evaluate their own
social-development efforts.
Concentrating, as we are doing here, on tl?e role of
health in Another Development, it should first be
pointed out that health has, for a long time, been
the exclusive preserve of a professional class - the
medical profession - and that this has had certain
unfortunate consequences. Thus, unlike other policy
issues,health issues have not been the active concern
of the community and no comprehensive view of
health problems has been formulated. The inferior
position usually assigned to health ministries by
governments and the almost total absence of health
issues in the national and international development
[email protected] is, in fact, a result of the splendid isolation in
which the medical profession has preferred to
perform its work.
Our practical problem today is to break down the
barriers created by the medical profession and
willingly accepted by society and to put health in
the centre of the debate and make it a real political
May it be that health, in an expanded and
refined definition, ‘can be fruitfully used as an
indicator of quality of life? And may it be that
health promotion itself can become, as Halfdan
Mahler, Director-General of WHO, has said, the very
lever for development? If that is the case, our
model becomes, almost by a stroke of magic,
poinad, goal-oriented and dynamic.
But is w- concept of health well enough defined
and able to channel a massive development effort?
Furthermore, how do our health senrices function
and to what extent can they meet these new and
high expectations?
Let us first look more carefully at the current
concept of health. It is both strange and disturbing
that, colloquially, the word health appears to have
meaning for us only as the negation of a state of
illness. It has no real content of its own, it has
become just a state of no-disease.
The health service system, which is so often turned
into a medical supermarket, displays the disease
problem so predominantly that we are incapable of
seeing the health problem What exists, then, in our
perception is the disease episode of the individual
and not the state of health of the community.
May it be simply that our concept of health is
The Western doctor basically diagnoses and treats an
‘Mated individual. He or she habitually makes
individualistic assumptions about the “case” and
society. Patients and human beings are mostly
viemrd as inherently separated from one another
and from their surroundings. What do the Western
health professionals know about the concept of
health in other cultures?
Studies indicate that the diagnostician fails to note
that the experience of symptoms - and the
consequent decision to consult a doctor or another
health worker - is as much a function of people’s
ability to cope with, and adapt to, their life
situation as it is a biological phenomenon. What
turns symptoms into medical problems are massive
failures on the part of individuals to manage the
stress that accompanies these symptoms. Should we
start recognizing that there is not only a medical but
also a so&cultural wncept of health?
In the Zulu concept ukeihngiza
- health - is not a
state but a wntinucus activity, an ende*wour to
restore order where there has been disorder. lsifo disease - covers Pr?3oniy bodily ailments, but also
misfortunes and vulnerability to misfortune, and
even repulsivehe& the condition of people who feel
they are unwpular and possible repugnant to
Good heaEth is therefore not just a matter of your
body being in good working order, but rather of the
whole u=vrld about you, with you in it, being
actively ktipt in a well-ordered and harmonious
condition. If there is sowthing wrong with a
person, it my be in his/her body, but it may also be
in the social setting or the physical environment
Gocd health is an expansive concept in this culture:
it also comprises the community and the ecology.
Societ&?swhich, supposedly, are “ridden by witchcraft” may be closer to an understanding of what
makes for a truly healthy life-style than those who
patronize the world with medical technology. No
wonder that the Western attempts at community
medicine heve always been failures. We have shown
gross disrespect for the people’s own health culture.
Another Development in Health must begin with a
mdefinition of our concept of health.
Valentina Borremans says : “Health is the autonomws coping with the environment”. A quotation
from Katherine Mansfield is also appropriate: “By
health I mean the power to live a full, adult, living,
breathing life in close contact with what I love - I
want to be all I am capable of becoming”.
The definition of health as laid down in the
constitution of WHO* has been widely used, but it
is not possible to apply it in its general formulation.
In practice, it transfers to the physician the
exclusive right to determine what wnstitutes
sickness and lets medical technology and professional satisfaction erode people’s self-confidence.
There is a glaring wntradiction in WHO’s policy
when, at the same time, it promotes the notion of
Primary Health Care, based on community involvement and people’s own capabilities to cope with
their health problems. A sociocultural redefinition
of the b&c health concept is needed if health is to
become the very lever for Another Development.
Our problem
is to turn health care from a
sewice into a self-reliant personal
care, exercised in collective forms.
And t5is we must do in a situation where major
health development institutions are still obsessively
promoting, in their recommendations and declarations, the notion of distributing, delivering,
providing or boosting health services. WHO in its
Hlork programme 197888 says: “If health develop
ment is an integral part of social development it
HloUld seem reasonable to provide (my italics) health
care...“. The Swedish International Development
Authority (SIDA) makes the following recommendation: “The Ministry of Health needs to take
“Health is a state of complete physical, mental and social
mll-being and not merely absence of disease and illness.”
extraordinary action to boost health services (my
italics) ...‘I. Those are examples of what we say
internationally while at the same time proclaiming
our !x!ief in Primary Health Care.
This is what leads to the “landrover syndrome”
which adds more to the pile of scrap iron than it
contributes to the development of Primary Health
We should seriously question whether our present
health developmant institutions are suitable tools
for the tasks ahead. In other words, will the
technicalities of the professional bodies kill what
Primary Health Care is all about?
The hospitals are isolated from the people’s health
problems. Ivan lllich may be right; the system has to
a certain extent become counterproductive. The
delivery of more cures and more medicines tends to
make people more sick. And even worse: the
“medical-service ideology” has deprived the people
of their creative potential, their precious ability to
act as a competent community upon solvable health
The ideology of service delivery is still a strong force
and one is led to ask: what did the medical system
actually deliver to the Third World?
Does not the experience of the last generations
indicate that improved hygiene and nutrition were
necessary conditions for the substantial decline in
mortality and the consequent growth of population? WHO now seems to have concluded that it is
questionable whether infectious diseases (with the
exception of smallpox) can be controlled by
vaccination in a malnourished population. The
impact of the syringe, the symbol of our
professional potency, has been small in comparison
with other factors.
Health as a lever for Another Development should
be viewed in the light of the probability that the
determinants of health in the future and in all
countries, sooner or later, will be behavioural,
environmental and nutritional.
This has drastic consequences for the setting of
priorities in medical research. Such research should
primarily concentrate on solving health problems by
the identification of behavioural and environmental
factors. If we gear the research to our real needs,
epidemiological and sociological methods become
more important than laboratory work. The contradiction is brought out bi ihe fact that some of the
greatest successes cbf clinical medicio5 are in the
treatment of conditiorti;: such as accidents, which
ideally should not occur. Who shall decide the
research priorities: the doctor, or society itself?
The doctor as the natural leader of the health team
is no longer unchallenged. The community will
eventually take over. It is not easy for doctors to
accept that medicine is not vitally concerned with
the major determinants of health. But let us watch
out. From the belief that medicine can do
everything, public opinion is in danger of swinging
to the equally untenable conclusion that medicine
can do nothing. Let it be said clearly, therefore,
that, even if it is on a primus interpares basis,
successful development
of environmental
community health cannot be undertaken without a
strong medical contribution.
But, before that can happen, the medical profession
must get its own house in order.
I he outlook for all countries, sooner or later is
that the expenditure on health services is growing
faster - in Sweden now twice as fast - than the
goss national product; with the growing demand for
health services, their weakness is laid open.
But let us recognize that “getting the house in
order” does not mean a superficial attempt at
increased cost-effectiveness, introducing new cost
control systems, new personnel training systems or
new technologies. It means a drastic restructuring of
budgetary priorities with a reallocation of resources
from the high-technology central hospitals to local
PHC programmes. The strength of the health care
system will have to be mobilized in support of the
primary health workers.
can the associations of doctors and other
workers be made to comply? Maybe the
of the doctors could be better geared to the
of the people if there was one single labour
for all health workers?
One attempt at health house cleaning well worthy
of attention was made in Canada in 1974 by the
then Minister for Health, Marc Lalonde. His working
document A New Perspective on the Health of
Canadians elaborates a “Health Field Concept”,
which is dynamic and action-oriented.
It projects
with clarity the social and environmental determinants of health: Life-styles and Environment in
interaction with Human Biology and Health Care
Organization. But, in my opinion, it stops short of
the final goal: people’s involvement. The model
remains a model for service delivery. Defining - as
Lalonde does -categories of “populations at risk” in
this mode of social marketing is synonymous with
defining consutner target groups in commercial
marketing. It is based on the notion of the passive
recipient. Converted into action, it will tend to
become manipulative.
Lalonde perceives the perspective and raises the
doubt: “The ultimate philosophical issue raised by
the Health Field Concept is whether, and to what
extent, Government can get into the business of
modifying human behaviour”.
What now about a9 our declarations and recommendations on Primary Health Care? Could it be that
they still are stuck in the old frame of reference? In
view of the empirical evidence of the failure of our
health delivery systems, WHO prescribes a new cure:
Primary Health Can., an intramuscular injection to
give the old system new vitality.
Could it be that we really think that Primary Health
Care can be injected into the system from outside?
What shall be useful for the system must germinate
and mature inside the system1
The need for community involvement is reiterated
in the declarations,
but in an abstract and
generalized way. This is the sad result of the fact
that health professionals seldom discuss social
Experiance from countries which have tried Primary
Health Care on a national scale shows that it cannot
be implemented if the vested interests of the
medical establishment are allowed to dominate.
Spokesmen for these countries would insist that a
plan .of operation for health must include a strong
party organization, controlled by the people and
committed to continuous PHC action programmes,
ranging from the digging of pit latrines to the
promotion of breast feeding. The health bureaucracy provides technical guidance, but it needs both
the motivation and the supervision of an independent political
How far are health
professionals willing to accept this kind of political
The role ot the woman in the PHC situation is of
particular significance. In the countries of the Third
World, she carries, because of frequent childbirths,
the burden of a mort$ity which is relatively much
higher than the rnan’s. Her workload is excruciating,
in gardening, weeding the fields, collecting water,
other household duties, and rhe rearing of children.
In this situation of overwhelming demands on her
labour, primary health and community ir,vc dement
lay further claims on her. She has a key ro,e in any
programme. It seems to me, therefore, that a more
equitable division
of labour in society is a
prerequisite for successful primary health development.
Through my experience, both in the Third World
and in my own country, Sweden, I have come to the
that what characterizes our health
development problems and their solutions, although
seemingly so different in nature, is that they have so
much in common. For me, the central problem and the solution - is people’s participation,
creation of a relationship of trust, which subordinates health work to the needs of the people and
thus marks an important step not only towards
in health but towards
Another Development of society.
Manzoor Ahmed
supported by their respective community, are the
frontline workers at the point of contact with the
Several essential features of the Primary Health Care
(PHC) approach, as it is generally understood, define
the nature and scope of community participation in
PHC programmes.
Primary role of local people
A health system directed towards the grassroots
First, the PHC approach requires that health-related
activities be shaped and carried out in conformity
with the life pattern,
needs, priorities
capabilities of each community. This contrasts with
a mere downward extension of the standard national
health service practices which, in any event, has
proved to be difficult and ineffective for a large
majority of people in the developing countries. The
organizational structure of the health service will
have to make a shift from drawing clients to a
hierarchy of central service locations (thus Iimiting
the numbers served and kinds of needs addre$sed) to
an organization
that, essentially, suppotis and
provides back-up for services organized and
performed in the communities. With this perspective
of the health service structure, the centre-periphery
analogy becomes not only inappropriate, but smacks
of a relic from conventional ideas of the past (even
when more services at the “periphery”
advocated). The basic thrust of the PHC approach is
that the centre of gravity of the health system
should shift from central urban locations to local
input, a crucial element
Secondly, communities, according to their capacity,
need to mobilize human, financial, and material
resources to supplement the resources provided by
the national government and other extra-community
sources in order to effectively carry out local health
improvement efforts. Selected community members
with a minimum of training, fully or partially
Thirdly, in the preventive and promotive aspects of
Primary Health Care, the community people are the
main actors, with the health service and extra-community agencies playing only a supportive role.
Collective and individual decisions and actions by
community members, with appropriate assistance
and input from the government, determine the
effectiveness of the efforts in respect to sanitation,
nutrition, environmental hygiene, supply and use of
pure water, precautions against communicable
diseases, and family planning.
towards better health
Finally, the PHC approach recognizes that the
health status of a community is affected by many
non-health factors, including access to such essential
goods and services as food, clean water, shelter,
clothing, and basic education. These factors together
have more influence on the health and overall
welfare uf the people than all the measures that
could be taken by the health service. Health care
provisions constitute a necessary, but not sufficient,
condition for improving the people’s welfare. The
and coordination
of the different
sectorial activities necessary for making an adequate
and sustained impact on health can be brought
about effectively
only at the community
through community action and organization.
It is evident that popular participation in healthrelated activities is the essence of the PHC approach,
and that it implies much more than passively
benefiting from the government health service.
A cdmmuflity, for the purpose of organizing a PHC
o: other development I programmes
requiring strong community involvement, may be
defined as a group of people which has a sense of
belonging to the same entity, has a common
perception of collective needs and priorities, and can
assume collective
for community
decisions. The collective participation
of communities in Primary Health Care assumes different
forms and varies in effectiveness and intensity.
The major dimensions of community
include at least tf;d following:
The organization of senrices on a community basis,
with wide and easy access to the services. This may
services and a mere
range from rudimentary
intention of eventual community-wide coverage, to
adequate provisions for basic health needs and truly
universal coverage of all community people.
The contribution
by the community
to the
operation and maintenance of the services varying
from small voluntary contributions in cash and in
kind to supplement government and other external
resources, to almost full coverage of costs through
the systematic allocation of communal resources
and individual payment.
The participation of the community in the planning
and management of the services within
community, which may consist of only an informal
and occasional consultation
by health service
workers with a few villagers, or the assumption of
full responsibility
for the programme by a
representative community body.
A community
input into the overall strategies,
policies, and workplan of the programme, which
may range from unsystematic efforts by wellintentioned
officials to understand
varying community
situations, to a systematic
arrangement for the participation
of community
people in policy making and planning at regional
and national levels, and for regular feedback of
from compertinent
munities into the decision-making
processes at
different levels.
The overcoming
of factionalism
and interest
conflicts in the community in order to achieve a
broadly-based participation, particularly on the part
of disadvantaged groups. The situations in this
respect ma;, vary from attempts to serve various
subgroups as equitably as possible, recognizing the
reality of interest conflicts within the community,
to the emergence; of cohesive communities capable
of engaging in cooperative efforts for the benefit of
The work of the joint review committee of the
WHO and UNICEF Secretariats and other recent
in rural
studies of community
development efforts, including Primary Health Care,
have made it possible to discern broad patterns of
predisposing conditions in the larger society and
factors internal to the operation of the programme
which enhance effective community participation.1
A national
to meeting the people’s
It has been possible to make substantial progress
towards adopting and implementing
the PHC
approach on a national scale with a high level of
involvement ir situations where the
national political structure has made it possible to
mitigate the effects of the system of privileges and
the unequal social and economic relationships
within rural communities, and to commit national
resources to the basic needs of the common people.
In the absence of such an overriding national
commitment, genuine community involvement can
be generally found only in small-scale programmes
in specific locations, guided by highly dedicated
individuals with charismatic leadership qualities.
A strong national commitment, reflected in clear
and forceful central government priorities, policies,
programme objectives, and general programme
decisions in favour of Primary Health Care and other
basic needs can go hand in hand with a high degree of
of planning, management, and
operational decisions to the regional and community
levels. UNICEF/WHO studies describe examples of
strong community involvement with decentralizsd
management within
the framework of unified
national programmes in the People’s Republic of
China, the Socialist Republic of Viet Nam, Cuba,
Tanzania, and Yugoslavia.
Primary allegiance
In relatively effective examples of community
participation, as in the UNICEF/WHO studies, the
health workers - trained for specific,
tasks, and given
essential, and widely-needed
continuous support by a hierarchy of paraprofessional and professional health workers - belong to
the community they serve, are chosen by it, and are
fully or partially supported by it. In an effective
programme, the health worker is accountable to the
community, and his/her primary allegiance is to it
rather than to a government department.
In many programmes, it is the traditional
attendants and healers who have become the
workers. Examples of traditional
attendants with some training and supervision being
utilized for family planning services and maternal
and child health care are found in many countries,
though not always in the context of a comprehensive PHC programme.
of the community’s
Substantial financial and human resources can be
mobilized from the community, some of which may
otherwise remain unused, such as the enthusiasm
and energy of youth and women for community
action. Communities with institutional
such as a local government council, a cooperative
society, or a commune, which have a degree of
control over the community’s productive assets, can
mobilize resources for community purposes more
easily than those relying on voluntary and individual
In underdeveloped
rural communities, what they can mobilize can be only
supplementary to resources provided by the national
government and other external sources. The primary
health care strategy is not a means for reducing the
share of national health care allocations for rural
areas, but a way of utilizing effectively the resources
a nation can afford for health care.
The Chinese and Vietnamese
instance, shoulder most of the local health care costs
out of their own resources. In voluntary projects in
Bangladesh, India, and Guatemala, for example,
small regular contributions
by rural families
subscribing to, a kind of “group health insurance
scheme” cover up to one-half of the total costs for
Primary Health Care in the community.3
remaining half or less can be more than covered if a
portion of the per capita national government
expenditure for health is redeployed to the PHC
programme. The result can be a radical improvement
in the quality and coverage of health care for ,lhe
rural people.
Strong local institutions
and cross-sactorial activities
Community participation in its various dimensions is
more likely to be found in situations where local
organizations - an area development agency, a local
govern men t body, a voluntary
society, or a
commune - have wider development responsibilities
than just one or more aspects of health care,
although special local committees or groups may be
formed for health-related activities under the aegis
of the parent organization. Since the interests and
needs of people transcend sectorial jurisdictions,
genuine community participation on the basis of
people’s interests and needs calls for integrated,
crosssectorial development efforts, at least at the
It is interesting to no’te that many of the small-sc;rle
non-government programmes included in recent case
studies started with only a health focus, but soon
attempted to expand their scope of activities into
agricultural production, basic education, women’s
programmes, etc., as the interrelationship
health and other basic needs became obvious. While
programmes can cut across sectorial
boundaries, depending on their resources and
concept of development, integration and coordination
of government
programmes, with their
necessary jurisdictional limits, call for strong local
government structures or other local institutions
capable of overseeing various sectorial activities at
the local level.
Problems in multiplying
the impact of small-scale
In many developing countries, non-governmental
voluntary organizations have played an important
role in introducing
processes and
forming participatory institutions in the context of
their own health care and rural development
programmes. However, their impact has often been
limited in the absence of political and economic
structures sufficiently
conducive to a vigorous
national effort to pursue the PHC strategy in
conjunction with a basic needs-oriented national
development policy.
Dedicated and able local leadership has almost
invariably been vital in the success of the voluntary
programmes. These small-scale programmes with
positive experience in community
appear to share the problem of how to transfer the
lessons of their own experience to large-scale public
programmes and how to multiply the impact of
their efforts. Collectively, however, the small-scale
programmes have made an international impact in
heightening the awareness and demonstrating the
possibilities of the community-based primary health
care approach.
The recent studies of PHC programmes as well as the
historical review of broader community development efforts point to many obstacles in the way of
cooperative community action for self-help and the
growth of the participatory process:
Diversity of interests and priorities
due to social
One basic problem is that the group cohesion and
similarity of interests and perception necessary for a
collection of people to behave like a community are
far from universal phenomena. The rural areas of
developing countries are often characterized by a
highly uneven access to productive resources such as
land, water, and capital; traditional social stratification and separation based on castes, ethnic origin,
religion, and sex; and political and economic
institutions and practices that reinforce the existing
structure of privileges and create new privileged
medical practitioner,
the usurious
The “quack”
money lender and the large landowner may be the
same person in the village: or if different persons,
they will have a common interest in maintaining the
status quo that preserves the system of privileges
contrary to the interest of the rest of the villagers.
Even such a seemingly innocuous change as the
introduction of community-selected health workers
may pose a threat to the existing village power
structure acd open a floodgate of social change,
especially if the innovation calls for the democratic
participation of all the village people, unless, of
course, the whole process can be sufficiently
controlled by the village “notables”. The interests,
priorities, and perceptions of problems of the
different interest groups in the village may not be
similar at all; in fact they may be in serious conflict.
The unhappy reality in many developing countries is
that, unless the structure of privileges and highly
unequal social and economic relationships among
the people are swept away by prior change in the
national political
structure, the creation of a
community spirit, the articulation of community
aspirations, and the people’s participation
in the
planning and management of community
programmes can progress only falteringly and in limited
Projects are often cited as examples of community
in situations where the national
political system has not yet established the basis for
cohesive communities and has not removed the
barriers to community
sometimes a closer examination reveals that, even in
these projects, community
means giving a voice in local decisions to the local
influential people, rather than to the most needy
and the deprived who may constitute the majority.
It may also be found that a disproportionately
share of the services and benefits go to the neediest.
In other instances, community participation means
seeking the local people’s compliance with predetermined central plans and programmes and extracting
financial and other contributions from them, rather
than a genuine partnership between the government
agency and the people.
resistance to decentralization
redistribution of benefits
Even when the general principles and objectives of
Primary Health Care and community participation
are accepted in terms of overall national policies and
goals, the tradition and attitudes prevailing in the
governmental bureaucratic machinery often stand in
the way of their translation into concrete action.
This tradition is reflected in the unwillingness to
decentralize the administrative structure, to entrust
authority and responsibility to community people,
and to make government programmes and personnel
accountable and answerable to the people they are
supposed to serve. This tradition, of course, is
supported and maintained by the stratified social
structure that separates the rural masses and the
educated, urban, and relatively privileged people
who staff the government system, including the
health services. It may be argued that the
bureaucratic inertia and the inability to translate
rhetoric into action are indications of less than full
national commitment
to a PHC strategy with
community participation; and of an unwillingness to
probe, understand, and accept the full implications
of such a commitment.
Failure to reorient entire health service to Primary
Health Care
The PHC approach can be undermined
communities can become victims of cynicism and
despair, if the nominal adoption of the PHC strategy
leads to a dichotomy in the health service structure:
“barefoot doctors” and “self-help” for rural people
and the poor, and hospitals and medical specialists
for town dwellers. It is not always easy for the
health establishment and national decision makers
to accept that the whole health service has to be
reoriented to the demands of Primary Health Care
and that PHC needs must have the first call on
national health resources. The surest way to
discredit the PHC approach and dampen community
enthusiasm for it is not to provide adequate support
to community-level
activities in the form of
essential supplies and an
supervision, training,
etficient referral arrangement.
In situations where there is no tradition
community involvement in development efforts, and
adequate local government structures or other local
organizations do not exist, it is a difficult and slow
process to create the mechanism and motivation for
community participation only in respect to health
care. It become: a pioneering effort, and to sustain
the momentum and motivation, the organizers of
the health programme must make an effort to
extend community participation to other spheres of
The dilemma, however, is that the absence of local
participatory institutions in the first place can be
usually traced back to a national political and
economic system that does not encourage decentralization of governmental responsibilities and does not
offer the climate for active community roles in local
Assuming that there is a general acceptance at the
level of the PHC strategy and the
importance of community participation, and that
there is a willingness to reorient existing policies and
programmes accordingly, a process can be initiated
and a number of practical steps can be taken to
in a PHC
enhance community
1. Reorientation
of change, the process of self-appraisal can become a
kind of national movement from which can emerge
a workable plan for 7 community-based
system, as well as the necessary health service
personnel willing and able to guide the plan’s
of the health service structure and
One essential step is the evaluation of the capacity
and limitations
of the existing structure for
delivering Primary Health Care, the adoption of
appropriate remedial measures, and the instilling
among the health service personnel of attitudes and
perspectives in conformity with the principles of
community participation and the new role of the
health se-vice. The most difficult
task is not
identifying the shortcomings of the present health
service, or the changes needed in its organizational
structure, but changing the attitude and values of
the personnel who have to implement the new
mandate for the national health service.
An approach that should prove effective in bringing
about the necessary change of outlook among the
health personnel and, at the same ti’me, in
introducing the necessary reforms in the health
service, is to engage the health personnel themselves
- from the top planners and managers in the
ministry of health to the lower-echelon medical
professionals in the field - in a process of
self-appraisal and self-education. Small mixed teams
of health personnel from the national and regional
offices can go out to representative rural areas in the
country to investigate the health status of the
people, the performance of the government health
service in relation to their basic service needs, the
functioning of the traditional health system, the
amount that villagers spend (or misspend) for health
care, the opportunities for mobilizing financial and
other resources in the village for health care, existing
village institutions
as possible underpinnings for
village-based and -managed health programmes, and
so on. Personnel from individual health institutions
such as the hospitals, research centres, training
institutions, and departments and units of the health
service can examine and analyze what they can do
to reorganize themselves, to redefine their functions
and goals, and to produce the needed manpower for
a PHC strategy with community
participation. The results of the investigation and
appraisal can be compared and analyzed to identify
and formulate the plan of action at different levels
and for different parts of the national health service.
It would be as much a process of discovering the
facts about the health service and preparing plans
for the system’s reform, as of reeducating the
Encouraged and prodded by the minister of health,
with the support of other top government and
political leaders, and with appropriate guidance
regarding the crucial health issues and the direction
2. Diagnosis of the situation
in individual
Following the national appraisal and the formulation of a national strategy, an early necessary step is
a diagnostic exercise to identify and assesspertinent
factors that affect communi:y
particular localities.
The essential elements of the assessment are:
- 52udy of the various groups within the community. The basis for selecting the aggregation of
population that can effectively organize itself for
community participation can then be determined.
Prevailing administrative
units, natural geographical boundaries, and cultural affinity are
important considerations in this respect. While
existing social divisions need not be reinforced,
factors which help generate a sense of community
should be taken advantage of.
- Survey of the community’s
resources and
constraints. Its general socioeconomic situation,
the productive resources and potentials, the status
of the social services and institutions,
condition of the poor and disadvantaged segments
of the population, and the community’s social
structure need to be studied. These factors will
determine the environment of cooperative development efforts in the community, the nature of
prospective community involvement in development activities, and the potentiality for mobilizing the community’s resources.
- Survey of the community’s health status and
health care needs. Basic objective information
about the health situation - disease pattern,
age-specific mortality, birthrate, sanitation and
water supply, nutrition
status, the nature and
extent of available indigenous medical care needs to be supplemented by the population’s
subjective perceptions about the most serious
health problems and the most urgent health care
needs. This information
provides the basis for
deciding on priorities for the community’s health
care programme and for organizing appropriate
motivational and educational action.
- Examination of the adjustments needed in the
nationwide strategy for Primary Health Care. A
rigid nationwide
of approach is
neither practical nor in conformity
with the
principle of community participation. The diag
nostic exercise should provide the basis for
responding to the variations in the circL,mstances
A new herim promo-r
at his post in the community
of Alsspongo,
of the local communities within a framework of
national objectives and performance criteria.
Basic diagnostic tools: self-appraisal and dialogue
This diagnostic exercise should not become an
elaborate social science research project costly in
time, money, and expertise, and beyond the means
of local communities
or even many national
governments. At the initial stage, however, the
health service personnel and other concerned
agencies have to develop and learn a diagnostic
methodoiogy by engaging in a “iearning-by-doing”
process. The self-appraisal project mentioned above
will provide useful experience for this exercise.
Social scientists from universities and research
organizations, with special interest in rural and
community development, can be of assistance.
Eventually, the diagnostic exercise should become a
fairly simplified,
quick, and relatively standard
process, carried out under the guidance of a local
administrator who is responsible for supervising the
community health workers. This simplified diagnostic method can be applied to all communities as
the community-based health care system expands
True to the spirit of community participation, local
people should be extensively
involved in the
diagnostic process through formal and informal
dialogue and discussions, and the findings and
conclusions of the exercise should be validated and
verified through this interaction.
3. Devising and improving modes and mechanisms of
In situations where a community is a political and
economic unit with wide jurisdiction
over local
government and productive activities, or where a
strong representative local government body has
substantial authority and responsibility
for local
affairs, the institutional
structure for community
participation in respect to health care already exists.
In these situations, the main concern would be
extending the benefits of the programme equitably,
making the participatory bodies truly representative,
the health activities
with other
development efforts, and improving the overall
quality of health care; in other words, improving the
of the existing participatory
institu tions.
Where the institutional structure does not exist or
the local government body is without substantial
authority, an appropriate participatory mechanism
has to be devised or existing weak ones have to be
rejuvenated. On the basis of a national appraisal and
the local diagnosis, it has to be determined to what
extent traditional and existing institutions, whether
formally or informally constituted, such as village
councils, neighbourhoor’
associations, youth and
women’s groups, can serve the purpose; what
modifications may be needed in existing institutions
to ensure effective and fair participation; or whether
new mechanisms are required. When new institutions need to be devised, initially, at least, the scope
of participation will be narrow and limited to the
health programme. Eventually, these new institutions may evolve into multisectorial participatory
organizations, provided the communities so desire
and the government policies support such a move.
Balance between local responsibility
protection of the weakest
and government
In all situations,
and the right
conditions must be created for a free expression of
views and genuine dialogue. It may be necessary for
the health service and the community representatives to jointly set some guiding principles and
criteria regarding democratic community representation and equitable sharing of responsibilities,
obligations, and benefits; These criteria should not
lead to frequent bureaucratic interventions in local
programme activities and the stifling of local
initiatives. However, the health service or appropriate national government agency must ensure that
the vital interests and rights of the weak and the
needy in the communities are not violated by local
4. Use of the educational process
- in conscientizing the community. In addition to
the uaal health education activities, and distinct
from the training and retraining of different types
of health workers in the ctimmunity, a continuous and vigorous educational effort is needed to
get across to the people - accustomed, on the
one hand, to the bureaucratic neglect of their
plight and, on the other hand, to a paternalistic
handout approach in government services - the
premises of the PHC approach, the obligations
and responsibilities of the government and the
local people, the principle of accountability
the programme and ik workers to the community, the tenets of democratic participation and
sharing of obligations and benefik, and the need
for the community
people to organize and
prepare themselves for greater self-management of
community affairs.
This educational process does not necessarily
require special “educational” activities; rather, an
educational approach needs to permeate all the
activities of the programme. The participatory
process itself through the opportunities
dialogue, discussion, and involvement in planning
and decision making becomes an educational
prc~cess, creating a critical awareness among the
people of the rOOk of their problems and of
approaches to tackling them. All the workers of
the programme must become educational workers
as well, and the educational dimensions of all
programme activities must be identified and given
recognition in the planning and implernentation
L- -in preparing
the workers. The educational
process, obviously, is not a one-way street. The
programme workers and organizers at the local
level and above also have to learn to understand
the local environment and the socioeconomic
structure, the ways of promoting and supporting
local initiatives, and ef:ectlve approaches for
communication and eaucation. The training and
preparation of the community-level workers and
their supervisors have to take into account not
their technical
tasks, but also their
educational responsibilities. The workers have to
be made aware of their educational role, and
encouragement and opportunities given to play
that role. Together the community
and the
personnel must learn to work
effectively to improve the people’s health and
- in conveying health-promoting information. The
educational approach for the enhancement of
community participation, to have any substance,
must be accompanied by a strong emphasis on the
health education component in the local health
programme. The community-based health workers themselves have to be convinced of the
origin of the common diseases;
designated health education tasks have to be
identified and made part of the normal routine of
health workers at the community level and above;
and the health workers have to be ready to take
advantage of all local organizational media such as
women’s and youth groups, adult education
groups, and primary schools to disseminate health
information and to discuss actions the community people can take collectively and individually
to improve their health situation.
. Cooperating with voluntary
- in organizing innovative projects. The special
of small-scale non-government
projects run by voluntary and non-governmental
organizations make them good instruments for
testing and developing innovative community
participation approaches that might be difficult
and costly to try in large-scale public prothe
grammes. A practical way of facilitating
application of the lessons from these experiences
to government programmes would be to embark
on a “joint venture” by the government and the
Pilot projects can be
organized in one or more specific locations once
the viability of an idea has been demonstrated in
small-scale projects, and some basic criteria of
viability and feasibility (such as compatibility of
objectives between the private projects and a
national programme, the cost structure, etc.) for
their large-scale expansion appear likely to be
- in ensuring the participation of the disadvantaged.
Besides being the testing ground for innovative
techniques, voluntary organizations can also serve
as an institutional
mechanism for promoting the
participation of the disadvantaged and the weak
segments of the population
in the local
government structure and other local planning
and decision-making
bodies. Local voluntary
actions and efforts to organize homogeneous
interest groups among the poor and the deprived
for collective self-help activities, can prevent the
local decision-making bodies from being captured
by the powerful
The voluntary
organizations can serve as complementary
primary organizations and, to a degree, as the
force for community-level
regional planning and decision-making
6. Experimentation
the community
and phasing of development to
The implementation
of a PHC approach with
effective community participation has to be viewed
as an evolving process. While it u important to adopt
appropriate national policies and objectives and to
demonstrate national commitment by launching a
nationwide programme, it may not be possible to
totally reorient all at once the existing health
service, to solve myriad operational problems, and
to make the right choices in many novel situations.
It may be advisable to introduce the different
dimensions and levels of community participation in
phases as both the community people and the health
service personnel learn from experience and grow in
skills and confidence.
Even in a nationwide programme, selected representative localities may be designated as experimental
zones where the operation of the programme may
be closely monitored, variations in certain practices
tried out, and the impact of the programme
analyzed, the results of which then can be used to
improve the whole national programme. The
experimental zones may be the testing ground for
such questions as the interrelationship between the
in the
and other development needs, the
degree and nature of local management responsibility, the health-related problems in the community
which can and should come under the purview of
the health programme, the amount and kind of
resources which can be mobilized locally, the
education and training strategies, the role of the
the maintenance
improvement of the quality of service, and the
collection and feedback
evaluative information.
of pertinent
service and
A hiah-level task force or unit at the national level
(or at the regional level in a large country) has to be
entrusted with the responsibility for determining the
issues, planning and guiding the
experiments in collaboration with the regular health
personnel in the zones, monitoring and assessing the
results, and examining their policy implications.
7. International
action in support of PHC
International, bilateral, and other external assistance
agencies supporting the adoption and implementation of the PHC approach in developing countries
can enhance the effectiveness of community
participation in various ways.
- Consideration of the needs of the poorest in
project aid. The issues and concerns related to
community participation, including access of the
to the health
poorest in the community
programme and the democratic representation of
all segments of the population in the participatory process, can be raised and explored in
considering all assistance projects.
- Encouragement of experimentation
to improve
PHC. International
assistance should encourage
and support activities with multiplier effects on
the quality
of community
PHC programmes. Such activities
would be the management of experimental zones
as mentioned above, cooperative pilot projects by
government and voluntary organizations, development of means to improve the skills and
of health administrators
workers in promoting community participation,
and establishment of diagnostic and planning
techniques for community programmes.
- Support for international and regional information networks. International support should be
provided for activities which require international
and regional cooperation, which are not easy to
undertake for individual
governments. Such
activities may be the regional and international
exchange of ideas and experiences through
workshops, seminars, study tours, and the
exchange of training materials and other documents; the identification, monitoring, and evaluation of significant experiences for the benefit of
all struggling with comparable problems; and the
comparative review and analysis of regional and
experience in health care and
community participation.
- Self-evaluation
in terms of effectiveness in
International and other external agencies need to
examine critically their own responses to need for
assistance and their effectiveness in promoting
in health care programmes. They need to examine their own
organizational arrangements, institutional
practices, and personnel capabilities, and consider
ways of equipping
themselves to face the
mounting challenge of ensuring adequate Primary
Health Care for every community.
- Collaboration among UN and biia terai agencies.
WHO and UNICEF, having taken the lead in
the PHC approach and drawing
attention to the role of community participation
in this approach, should explore ways of
cooperating with other UN and bilateral agencies
in promoting
the concept and practice of
community participation for development.
It must nonetheless be remembered that community
participation is not an end in itself. The ultimate
aim is to deliver better health care and to increase
people’s welfare. This is the ultimate test that has to
be applied in judging the value and effectiveness of
participatory activities. Unless it contributes to the
improved health and welfare of the community, the
process becomes empty ritual and
token gestures.
1. Unless otherwise stated, references to specific examples in
this section are from Alternative
approaches to meeting
basic health needs in developing
a joint
study, edited
by V. Djukanovic
E.P. Mach, WHO,
1975, and Community
in Primary Health Care: a study of the
process of community
motivation and continued participation.
Report for the 1977 UNICEF/WHO
Committee on Health Policy, Geneva, 1977.
2. Maria de Lourdes Verderse and Lily M. Turnbull,
birth attendant in maternal and child health
and family planning,
WHO, Geneva, 1975. China has
indigenous medical practices
and personnel into the national system. In India, a
considerable research and training effort has been devoted
to enhancing the contribution
to national health care of
the Ayurvedic system, on which a very large number of
people, particularly
in the rural areas, depend almost
3. International
for Educational
“Case studies of BRAC and Savar Projects in Bangladesh,
and Social Work and Research Centre Project in Tilonia,
Rajasthan, India” (Drafts); K.W. Newell fed.), Health by
the people, WHO, Geneva, 1975.
Much has been written about the reasons for the
need to include community participation in health
care planning. Among these reasons are the need to
increase scarce health resources by utilizing
community resources such as local personnel and
medical treatments which heretofore
have been ignored; the commitment of a community
to carry out health plans in whose formulation it has
been involved; the value of using local people to
teach their neighbours about good health behaviour
and the motivation of these people to stay and serve
in their communities rather than moving up the
ladder of professional advancement. All these
reasons are valid whether community participation
’ is viewed as a component or the context of health
service delivery.
The difference in the two approaches is whether the
community is the subject or object of health care
planning. It is not a matter of the degree of
that is, whether the community
leaders are asked their opinion about health care or
work with the planner to formulate activities. It is
basically a question of whether the community
actively takes part and makes choices about resource
allocations or remains passive only to be consulted
by the experts. A strategy for the former, as we have
already noted, develops in a completely different
context than the latter.
This section looks at specific strategies for
community participation. The first two selections
present the broad framework in which the other
three health-related case studies might be viewed.
Marie-The&e Feuerstein discusses the links between
and health care programmes. Using the framework of community
development which grew out of the Anglo-American
experiences in the first half of the 20th century and
became adopted by the UN in the 1950’s, this piece
explores the relevance of the community development principles to rural health work. By looking at
this strategy, Feuerstein places health work in a new
It is a context
which sees health
improvements more as a learning process than a
transfer of technology;
more as a result of
community motivation than of increased numbers
of trained medical personnel.
Mary Racelis Hollnsteiner
looks at the power
relationships of a strategy for community participation. Analyzing six modes of participation from
of the community
grassroots decision making, she discusses various
policy implications for planners who are going to
develop this type of strategy. In doing so, she
presents a typology
of degrees of community
involvement. This article assesses participation in
human settlements rather than health, but the
framework remains relevant to health planners.
The remaining three reelections document strategies
specific to health care in three different countries in
three different parts of the world. From Asia,
D. Banerji discusses a possible alternative health care
system for India. Within the framework of political
economy, he surveys the history of health service
development in India and notes its failure to improve
the health status or health (a distinction which he
poor rural
He explores the alternatives and suggests important
immediate actions which particularly concern use
and deployment of personnel.
Merces Somarriba’s article explores the problems
and potentials
of a community
strategy which emerges from a traditional, capitalist,
society when one of the
government units takes seriously the dictum of
health by the people. By examining the effectiveness
and efficiency of health care, she develops a conflict
model of decision making in community participation that emerges from a situation
government and communities do not share the same
objectives. The study, an original piece based OR
Somarriba’s PhD thesis, highlights points of tension
likely to develop in any country where the existing
impede the
realization of the goal of community participation.
To gain a perspective of a strategy for community
participation in a strict interpretation when shared
and promoted by a national government, Budd Hall
describes the mass campaigns for health improveReferring to the Chinese
ment in Tanzania.
experience, he discusses how sharing the Chinese
view of the potential of people at the grassroots, the
Tanzanians attempt to develop an educational
process to bring out this potential. Although mass
campaigns have had a history of use for disease
control in various countries, they have not been seen
as a strategy to change the people’s views of their
society and themselves. Hall’s study analyzes the
direct relationship between health care and social
A Multitude of Definitions
The term “community
approach” is much used at
present among those attempting to confront the
problems of rural health in developing countries.
But interpretation of the term varies widely.
There is, for example, an increasing tendency to
regard a community as the “patient”, amenable to
“prescribed” accordingly. This is regarded as one type of
community approach.
A further type is where a vaccination
attempts, as an initial step, to gain public
and cooperation. There appear to be few
to formally define the term and it is
presumed to be understood, albeit in
a vague
However, the term “community
development” or
CD is not always understood by those engaged in
rutal health activities. CD is a specific approach, a
pattern of well-established practices emanating from
certain basic principles, attitudes and objectives.
And, although often in operation in close proximity
to rural health activities, health personnel are
frequently unfamiliar with its implications.
CD and Health - Some Links
In 1954, the WHO Report on Health Education
(TRSB9)l did not emphasize the need for any
special knowledge of the CD approach. However, by
1958, a further report in the series (TRS 15612
pointed out that training in health education should
be made available to workers in other fields
including CD and that health workers had the
responsibility to assist with CD programmes. Thus in
4years, CD had not only been recognized, but
special training in this field was felt to be an
essential part of the training of all health workers.
In some developing countries, the CD approach has,
in fact, been used in rural health improvement
activities, as for example well and latrine construction projects. But it has not been used extensively
and never in its most comprehensive sense. Rather, a
few techniques have been “borrowed”
in order to
achieve certain health objectives. There is evidence
to suggest that today, where CD does form a part of
rural health activities, it Is usually regarded as being
distinct from them and slightly oblique to the health
activities. For example, in a Korean rural health
project, “a community development effort (was
envisaged) to encourage the local residents to
in cooperatives and other self-help
projects”.3 And from a Nicaraguan rural health
project, “The community development workers will
try to create an awareness of the possibility of
progress to replace the apathy which is at present a
brake to developmen t.“4
In the main, rural health activities (both curative
and preventive) have often been “o-scribed”
any trace of popular consultation
“There are far too many examples of social
indifference and even arrogance on the part of the
health professionals towards the consumers... this i?
one of the root causes of the under-, or improper,
utilization of health services... It is most important
that the consumer’s social preferences, needs,
interests, aspirations, goals and values should be
identified... and that these aspects are allocated a
carefully considered and reasonable weight in the
planning and implementation of health care...“5
The Search for New Approaches
In Nigeria, a cholera prevention
attempted to influence the members of one rural
community individually
- in the traditional manner - while in another, it aimed at securing
community approval. It was subsequently found
that, in the first community, 45% of the population
reported for vaccination, while in the latter, 73% of
the community responded.6
Controversy continues today as to which particular
approach is the most feasible,
preferable or desirable.
At a symposium in 1970, Professor Maurice King
enjoined health personnel to “peer over the top of
the accepted and look round the edges of the
conventional... our predecessors used their microscopes well; our challenge is to use the instruments
of our time with equal determination and with equal
While many health personnel are by no means
reluctant to consider “peering over the top of the
accepted” in the search for new and more effective
approaches to the problems of rural health, the very
magnitude and complexity
of those problems
appears to weigh the scales heavily against them.
Rural Health Problems They Occur
The Context
in Which
The young mother of five children was carried into a
rural dispensary, after many hours journey on a
makeshift stretcher. Having been in labour for two
days, she was unable to give birth to her twins. The
personnel and facilities of the dispensary couid not
provide the caesarian operation that she needed. By
the time she was carried into the nearest health
centre, both she and the twins were dead.
The factors of poverty, isolation, and lack of
adequate basic health facilities conspired to produce
this tragedy, based on fact.
Other factors which continue to characterize rural
life in tropical and sub-tropical developing areas and
have a special bearing on health include the
heavy reliance on agriculture
employment of people rather than machines, which
influences nutrition,
economic resources and expenditure of human energy; continuance of the
extended family system; large family size and
frequently crowded living conditions; the “low”
status of women which still often prevents them
playing a fuller role in health activities; early
marriage and frequent childbearing; high illiteracy
rate and low educational
attendance; firmlyestablished and conservative leadership; high incidence of alcoholism; and the existence of an
intricate socioreligious system which affects the
interpretation and treatment of disease.
There is often a continuing reliance on hunting,
fishing and food gathering, indicating a food supply
unguaranteed in quality and quantity; the introduction of processed foodstuffs such as powdered
milk used in infant feeding, and atrophy of the arts
of food preservation. Little actual money may exist
in the economy, goods being exchanged instead.
Western medicaments, where available, are expensive, and crippling debts may be incurred by a
family in pursuit of cure.
The major “killing”
diseases in rural developing
areas include pneumonia, diarrhoeal diseases, tuberculosis, parasitic diseases, infections of the newborn
and measles. Then there are the so-called “silent”
diseases, “concerning which, people often prefer to
be silent, such as veneral diseases and leprosy. Other
prevalent conditions include trachoma (in some
areas more than :G% of the adults are totally blind),
infectious hepatitis and worm infestations which
cause a great deal of debility, but which do not kill
many people “.8 “Bi Iharzia”, yaws and hookworm
are responsible for widespread chronic disability and
Infant:. mortality
and maternal mortality
generaqy high; life expectancy is low; children,
(consti(tuting often 20% of the population) may
account for 50% of the deaths; standards of
domestic sanitation and hygiene are low and there is
reliance on indigenous and often
‘inadequate health practices and practitioners.
Reappraisal of the Status Quo
In the face of daunting odds then, health planners
continue to attempt to grapple with rural health
problems. But certain questions recur with increasing emphasis. Why, for example, do communities so
often continue to receive only the fringe benefits of
such efforts? Should only the health needs of those
who seek treatment be catered for? What of the
needs of those who do not attend at all? Is the local
health centre catering only to the needs of those
who live near it? What responsibility should the
itself have for the provision and
maintenance of its own health care? How far are
hea!th personnel being trained to regard the patient
as part of his community? Which are the factors
within the social and political structures of a
country which continually undermine health progress?
“We must not assume that health is being cared for
simply because a system of health care exists. We
must learn to recognize the right issues, find out
what are the right tools and put them in the right
hands. It may require developing approaches to
health care that are entirely new.“9
In many quarters, this entirely new approach is
increasingly being connected with a “community”
There are indeed many types of community
approach currently
being employed in various
countries. But personnel involved in such projects
are increasingly encountering the need to explore a
really comprehensive approach.
What follows
is an attempt
to outline
characteristics that such an approach would need to
have. However, it should be noted that nowhere, to
the author’s knowledge, is such an approach
operation at present in toto.
This approach is one by which individuals and
communities are helped to perceive, within the
context of the national health plans, their health
needs, (that is, the need to change belief and/or
behaviour in order to increase the incidence of good
health) and aided to remedy them by the utilization
of internal and external resources. The long-term
aim is improved rural health conditions
services, the responsibility for whose organization
and maintenance rests largely with rural c.ommunities themselves.
It is wholistic.
1. Health activities occur within
planned national development.
the context
many rural health activities have
occurred independently of planned national development or, more specifically, of the national health
plan. Practitioners of traditional
medicine, for
example, have, with some major exceptions such as
China and India, generally functioned independAnd until
the activities
and religious organizations
established hospitals and dispensaries in rural areas
have been little coordinated with national ones.
Where health activities have taken place in insolation
from the nationally planned ones, overlap, duplication and conflict have occurred. For example,
without a coordinating policy, an agricultural rural
development agency engaged in stimu!ating increased egg production for cash return found itself in
direct conflict with a nutrition programme in the
same area which was encouraging the increased
production of eggs for home consumption.
Without coordination on the one hand, activities are
pursued which are unrelated to nationally selected
priorities, and on the other, national health planners
are often unaware of all the resources available for
rural health activities.
Today, coordinating
bodies do exist in some
countries. Coordination itself is far from easy as the
health activities of, for example, religious organizations have emphasized curative rather than preventive or educative care, both of which may be
priorities of the national health plan. And an
unresoived question remains: how far is effective
liaison really possible between religiously-oriented
bodies who are in competition
on the theological
However, there are many examples of cooperation,
such as the missionary doctors of Zambia, who have
played a significant
role in training
A comprehensive community approach is a wholistic
one, and the process of its adoption is rendered
more difficult due to the “fragmented” nature of
present rural health activities.
It has Longterm Community
2. Long-term objectives include the evolution of
rural communities into healthy citizens, capable of
fully participating in their own lives, that of their
and nation, and assuming where
possible a greater share of responsibility
for the
delivery and maintenance of rural health activities.
The objectives of health personnel are often far
from clear to rural communities, and this has
resulted, on occasion, in resentment and conflict. A
South American study revealed that a community
found its health centre staff lacking in tact and good
manners: the staff considered themselves as being of
a higher socioeconomic
group and therefore
to the rural population.
For the
long periods of waiting preceded
attention, and most seriously, the centre did not
treat sick children. (The centre saw its role as
preventive and was not fully equipped for curative
To the community,
prevention was
unnecessary; one only needed treatment when
something went wrong. What they desired was
treatment for tneir children. They felt their primary
desires were being disregarded so there was little
confidence in, and cooperation with, the centre.
In the South Pacific, an assessment of a
programme concluded that, too
often, “latrines were built only to satisfy the desire
of administrative personnel, and unused they stood
there, mute symbols of the willingness of people to
cooperate”. 10 The community’s objectives then did
not include the acquisition of latrines.
Only a good communications system can ensure that
health policy makers are really familiar with the
objectives of rural communities, and vice versa.
When national resources are limited, it is important
for communities to understand the reasorls for
decisions about their allocation. And local health
personnel may have little idea as to the overall
national policies and, therefore, become easily
frustrated by seemingly inexplicable plans, shortages
and objectives. Communities also need to be aware
of the problems of health personnel. During an
indian rural health project, the communities were
asked to listen to the physician’s problems. Lack of
roads was a constant hindrance. Eventually, the
villagers constructed a ‘I-mile road themselves and a
local minister paved a further 50 miles of road.1 1
A criticism levelled at previous health activities is
that longterm objectives have often been obscure, if
not totally lacking. Statistical evidence of large-scale
vaccination has very often been regarded as a
hallmark of “success” with little attention given as
to whether deep-rooted popular attitudes and beliefs
have been changed or “merely” disrupted.
It has coordinated programmes and uses appropriate
technology and staff
3. Each country evolves a specific pattern of health
development consistent with its own traditions,
circumstances and aspirations. Special emphasis is
placed on the concepts of integrated development,
appropriate technology and the employment of new
categories of health personnel.
Until recently in many countries, the trend was to
adopt, and not always to adapt, patterns of health
activities formulated largely in other countries of
widely different socioeconomic and climatic situation. Today, the selection of a national health
pattern is, to a greater extent, influenced by
economic and political issues.
Countries with the greatest health problems tend to
have the least to spend on them. For example, some
countries provide health care with an annual per
capita expenditure of under one American dollar,
one hospital bed for 1000 of the population, and
one doctor and nurse for from lOOO-28,000
people.1 * (A ratio of one physician to 10,000
people is considered operationally feasible).
Curative care continues to be allotted the largest
“slice” of available resources, and in some countries,
8080% of total health budget is spent in services
in the larger population centres where only 1920%
of the population live.
In rural areas, who in fact does receive the care that
is available?
In many instances a “cafeteria”
approach has evolved where it is “first come, first
served”. Those who do not come, or are unable to
come, receive no care. But there is also the danger of
spreading health resources so thinly that they
become ineffectual.
Large hospitals traditionally
absorbed large resources, but smaller hospitals and health centres are
now being increasingly employed. “Auxiliary-staffed
health centres represent a substantial return in
human welfare for comparatively little expenditure
of money and skill”.13
Integrated Development
In the past, there have been specialized divisions in
rural development,
each pursuing a particular
problem, e.g., education, agriculture, or a specific
disease eradication target, and each with its own
programme, personnel and resources. Coordination
has been the exception rather than the rule. This
has, on occasion, detracted from
the overall success of such activities.
not regarding their own lives as
have been bemused by the
influx of various agencies, each concerned with just
one compartment of their lives.
There is a pressing need to view health problems in
their totality. Health is a social as much as a medical
problem. If, for example, the problem identified is
infantile malnutrition, then more than just improved
nutrition classes are needed. For the problem also
embraces socioeconomic
domestic hygiene, agriculture and food technology.
For the realistic confrontation
of this problem,
then, an integrated viewpoint is necessary. The aim
for, example, of an Indian rural health project was
“complete integration of curative, preventive and
promotional work so that there was no category
such as public health nurse or any other worker in
one specialized field alone .. . In a small rural health
clinic, it is important that each professional knows
more than his own skill”.14
In most developing countries, there are limited
resources for the purchase of the usually imported
technological tools and hardware of modern health
care. While some items such as instruments and
certain medicaments may continue to require
and adaptation
locally-available resources like wood and cloth for
trolleys and dressings, have proved both more
economical and appropriate.
Employment of Personnel
A central problem in the provision of basic health
care concerns the changing role of health personnel.
For example, “the physician must fill a role in
which he manages limited resources to meet the
comprehensive health needs of large numbers of
people, rather than serving as personal physician for
a few”. l 5
A further problem is the frequent reluctance of
health personnel to work in rural areas. In a central
American country, trained health personnel from
urban areas, according to the coordinator of a rural
health project, are “not only reluctant to work in
the isolated, culturally distinct (project area); they
actually refuse to work there. In some government
agencies, it is regarded as a punishment when one is
assigned to this area”. 18
Rural areas tend to lack the sociocultural and
educational opportunities to which personnel and
their families are accustomed. And lack of health
often hampers a high standard of health
Even where a part of medical education occurs in
rural areas or where postgraduate rural service is
compulsory, these measures are unlikely to provide
the long-term answers to the problem.
And the role of the nurse continues largely to be
associated with hospitals and health centres. The
nurse from and in the community is a relatively
new concept. “The nurse has a contribution
make to the total concept of health care that goes
beyond clinical activity and techniques, to encompass such things as education .. . nutrition and other
elements that ultimatelv
affect the health of
people”. l 7
The role of the nurse, however, varies according to
circumstances. In Malawi, for example, an auxiliary
nurse will often run a rural dispensary alone. “To
many patients, auxiliaries mean more than doctors,
they work long hours in lonely places”.t8
Auxiliaries are increasingly being regarded not as
measures until more highly-trained
personnel become available, but more as a new
category of worker in their own right. In an Indian
rural health project, auxiliary-organized community
care was planned in the villages in the form of
Under-fives clinics, antenatal care, immunization
programmes, detection of chronic illness such as TB
or leprosy, school health programmes, basic
sanitation and family planning. Indigenous practioners, teachers and other leaders aided them.19
A survey in 1971 of a Ghanaian rural health project
revealed that almost all diseases encountered were
readily diagnosed and treated by auxiliaries using
relatively few drugs.
Problems surround their role and status, remuncr:;.,ation, availability of further training opportu:;I&
and supervision. (Professionals are seldom trained
for this supervisory role).
The use of auxiliaries is increasingly seen as not only
holding a possible key to the problem of personnel
shortage, but also to the total effectiveness of rural
health care delivery.
It is related to the Community
4. An appreciation of the sociocultural context in
which health activities occur is considered essential.
“The success or failure of medical programmes
depends on many cultural factors besides competence of doctors and quality of services”.20 Lack of
cultural understanding has robbed many health
activities of their effectiveness.
In rural India, for example, a well- and latrinebuiiding programme was initiated. The wells were
successful. But the unused !atrines fell into disrepair.
It transpired that, in order to properly flush the
latrine, at least a quart of water was required after
each use. So, the larger the family, the more
intolerable had been the water-carrying burden on
the women. In Ghana on the other hand, the
pouring of “libation”
drinks and water on the
ground (the traditionally-prescribed
marked the inauguration of the Danfa rural health
project, and initiated the health activities in, a
fashion comprehensible to the community.
It has been asserted that medicines often work
effectively, despite total ignorance of a patient’s
culture. While this may often be true, it is yet a
narrow point of view. While a child may be cured of
unless his/her sociocultural
economic background is effectively
recurrence is almost inevitable and treatment is
poured into a vacuum with limited effectiveness.
Health personnel are increasingly enjoined to
bec,ome aware of the health beliefs and practices of
a community, the reasons for their existence, how
customs are linked to one another and how new
health habits often cannot be introduced by merely
“adding” them to a preexisting sequence, or old
habits merely “subtracted”.
Culture must be understood as it relates to health.
Why, for example, when children are malnourished,
will a .community not use the readily-available
protein source of eggs? Why is there a prohibition
on eating eggs? These and similar questions can
only be answered lith a knowledge of the context
in which they occur.
5. There is an appreciation
of the fact that
communities have distinct, valued and time- tested
be!iefs and practices related to health and disease.
Some years ago, a revolutionary new method for the
rapid healing of fractured bones was found to be the
very same technique as one that had been used for
centuries by certain South Pacific Islanders. And in
Africa, long before the advent of modern vaccina-.
tion, people had been rendered immune from
smallpox by vaccination with the scab exudate from
mildly-infected persons.
Some systems of indigenous medicine are well
developed, such as those of China, where the system
is practised concurrently, and also synthesized with,
Western medicine, and the Indian Ayurvedic system,
which is practised alongside Western medicine.
One of the most significant contributions
indigenous medicine has made to mankind is
knowledge of the natural remedies such as opium,
cocaine and eucalyptus, and “mind-influencing”
medicines which were used centuries before the
development of modern psychotherapeutics.
After a -study of Mexican Americans, Margaret Clark
concluded that “the causes of illness and mortality
and curative procedures are understandable and
logical in the light of (indigenous) beliefs . . . only to
be understood in terms of the total culture”.*1
In indigenous medicine, the patient’s physical,
psychological and spiritual needs are considered in
toto. Health care is rendered within the context of
the family, who represent a force to envelop and
protect the patient, help the practioner, remember
directions given and guarantee financial support. In
a Western context, this would be done by a
receptionist, lawyer, nurse, orderly, secretary and
In Western medicine, belief in disease causation
often ranges from the microbial to excesses. Missing
is the notion of an external agency such as a
malevolent spirit or person. Also missing in Western
medical care is the reassurance of recovery (even
where it is common knowledge that recovery is not
possible) which is often considered, in indigenous
terms, essential to adequate treatment. Also considered essential is dietan/ advice, and a multiplicity
of remedies may be applied as opposed to a single
As Western medicine is regarded as having its
failings, so too does indigenous medicine have its
own. These include inability of patients to seek
alternative treatment due to prohibition,
fear, or
undue conservatism, and the vulnerability
individuals or communities in the face of powerful
or unscrupulous practitioners. And some practices
have been proved to be harmful.
Many rural communities consider certain diseases
amenable to Western treatment and seek relief of
symptoms. But causation continues to be sought
from indigenous sources which often offer a
complex and detailed categorization.
Western medicine has mostly held
indigenous medicine in low esteem. Many of the
direct links between them have occurred only when
patients were brought to receive Western treatment
after indigenous methods had failed.
Today, indigenous health systems mostly exist
alongside Western ones or are “filtered out” as
direct conflict of belief results in their rejection. Or,
they are synthesized with it in such a way that their
beneficial aspects may be retained to enrich the
evolution of modern health care.
It attends to a Broad Health Education
6. Communities are helped to identify their health
needs; and to select those which are likely to bring
the greatest communal benefit synonymous
balanced local and national development.
Very often, the health needs of the community that
appear most obvious to health personnel are not
perceived at all by the community: they are “unfelt
needs”. In rural India, for example, health personnel
found that, “in certain villages, they just did not feel
there was any need for medical care and were quite
happy with what they had . . . the issue uppermost
in the minds of the villagers was not health but food
and water”.*3
The issue of compatibility
of rural felt needs with
national or agency plans sometimes continues to
defy a satisfactory solution. Do communities, it is
argued, ever really identify their needs? Or is there
often a “charade” of need identification
and a
“rubber stamp” of approval obtained for previously selected health plans? Often, then, few
resources are left for the longer-term aspects of
improved health care. And do the time and
resources exist anyway to attend to strongly-felt
needs first?
The process of need identification following just one
public meeting and a democratic “show of hands”
is considered a poor substitute for the slower pace
of systematic discussion. It has been found that
rural communities in the latter case are more likely
to choose a simple health post, than a multistoreyed
But guidance is needed in order for communities to
perceive that to confront a single problem may
involve attending to various needs. For example,
improving the health of “under-fives” may require
the provision of safe water, improved agricultural
food storage
techniques and fertility control.
Guidance is also needed with regard to costing the
desired health improvements and explanation of the
national health priorities and resources.
To achieve the necessary balance between curative
and preventive health care is hazardous because the
demands for curative care always seem to be more
It encourages Self-help
7. By a process of self-help, communities are
enabled to contribute resources and skills in pursuit
of chosen objectives. Use is also made of voluntary
organizations and technical assistance at local,
national and international level.
There is much that a rural community, however
impoverished, can provide in the way of resources
for health activities, for example, human resources
for labour and leadership (especially where cultivators dre only seasonally employed), inside knowl-
WHO photo D. Derias
III an Iranian
are being given
by a health
on how
edge of the community
itself, dnd materials such as
stone, wood, pottery
and weaving. At the same
time, self-help may not be a particularly
cheap or
easy method
of impro*iing
Indeed, it may be more costly in terms of economy
and time. During an African
rural health centre
many problems
disputes over the token wages, deaths necessitating
heavy rainfall, traditional
rivalries, etc.
During the last stages of construction,
the whole
labour force was engaged by the project.24
But there is evidence to suggest that self-help is
often more effective in the long-term as it affects
many aspects of community
life, guards against
on outside assistance, mobilizes community
is an educational
process and is
related both to self-respect and self-determination.
In the Philippines,
a free medical clinic for the poor
evolved into a medical cooperative.
leaders had met the medical staff and
to cover
a well to protect
the water
a plan whereby the treatment costs were
related to peoples’ ability to pay and the cost of the
medicines involved. Then, “the people came to the
clinic with clean clothes and scrubbed bodies. The
end of the dole-out phase saw the commencement
of a new pride among the people in themselves and
in their medical cooperative”.*5
Outside assistance should encourage self-help, not
take its place. For when aid is poured in from
outside, the undertaking
is no demonstration
what communities
themselves can do. And, in the
past, aid has been tied to projects acceptable to
donor agencies. Hospitals, on occasion, have been
where there were no personnel
resources to run them.
The pace of self-help may appear too :,iow where
visible results are required by an external agency.
But haste undermines real self-he!p in that it seldom
allows adequate
time for the attitude
to long-term health improvement.
It encourages Community
8. Various types of community
leadership are
identified and individuals approved by the community are selected to receive leadership training.
Rural leadership is often a vital factor in the success
of health activities. Where community leaders have
perceived that these activities pose no threat to their
own status, they have proved invaluable allies.
The identification
and selection of leadership for
rural health activities remains mar? an art than a
science. Part of this art often consists of identifying
certain personality characteristics allied to mental
aptitude and certain job-related skills. Those who
have initially
“rallied to the cause” have, on
occasion, proved to be ineffectual leaders for health
purposes, perhaps being self-ambitious or malcontents, with little community standing and limited
enthusiasm However, the more retiring “informal”
or “opinion”
leaders, such as the middle-aged
mother of a large family
to whom others
automatically turn for help, or the elderly respected
religious leader, have proved to be of greater
One aim, then, of a comprehensive approach in rural
health is to promote action by groups within the
community, led by the community’s own leaders.
In Nicaragua, an objective of a rural development
programme was to train village health leaders:
“someone chosen by his own village with efficient
to be able to distribute
medicaments in accord with his judgement of
common diseases and be able to administer
injections for vaccination and TB programmes, in
far-distant areas”.26
These leaders were sup: rted by a medical
committee comprised of villagers who supervised the
ordering of medicines, payment of the leader, and
cooperated with government programmes. This type
of leader is the precursor of the “Village Health
Worker” or “VHW” recommended by WHO.
It minimizes
9. The simultaneous involvement of all or many
sections of the community at each phase of the
approach is seen as contributing
to its long- term
effectiveness and minimizing the disruptive effects
of change.
In a community, few, if any, changes occur in
isolation. Rather, they affect the whole community
to some degree. Within this whirlpool of change,
health activities take place. If the interrelatedness of
rural life is ignored, their impact may be minimal
and their effect disruptive.
If, for example, a clean water supply is installed but
disposal means are lacking, mud holes will appear
and breed diseases; without trained personnel, the
machinery will fail . . . violence will be done to
many social customs; women will be deprived of
their social opportunities over wash tubs or youths
may be deprived of courting opportunities at village
wells.27 The “simple” supplying of clean water is, in
reality, a complex innovation.
In practice, then, “simultaneous
includes recognition of, for example, the facr that
individuals and groups are part of kinship networks;
that identification
with one group often automatically incurs the opposition of rival groups who
may then refuse participation;
that older people,
while resisting change for themselves, may well
accept it for their chfidren iwho are often more
high!y-educated than their parents); that the use of
friendship groups carries with it the extra safeguard
of friendship against the possible disruptive effects
of the change.
In many health activities, there is still a continuing
tendency to regard change as good per se. In the
light of experience past and present, that assumption can no longer stand. For it has been seen that,
where disruptive change occurs, it often provided a
legacy of emotional and psychological disorders. In
the process, then, of attempting to bring healing and
health to the “body” of the community, much harm
may inadvertently be done to its “mind”.
It gives special Emphasis to Women’s Health and
their Contribution to Family Health
10. Special emphasis is placed on the involvement
of women due to their influence on family health
and role in community health.
In most developing countries, children under the age
of 15 years and women in the chiLlbearing age
(15-44 years) form over 60% of the total
If women are even to begin to play their full role in
rural health activities, they first require to be in
adequate health themselves. But many factors
conspire to prevent this. These may include
anaemia, parasitism, malnutrition, chronic ill-heal,th,
early marriage and constant childbearing, povevty,
heavy manual labour, illiteracy, and lack of b$sic
health care and fertility control opportunites.
Lack of adequate care during pregnancy, childbirth,
and up until the next pregnancy - usually in the
following two years 7 is often a central factor in the
state of health of a rural woman. Usually, she
receives care during pregnancy and delivery, both
from her kinswomen and from a “traditional birth
who is often an elderly woman of
considerable community prestige, skilled to varying
degrees in the art of birth attendance. In some
countries, inclusion of these attendants in health
programmes has proved to be beneficial both to
themselves and to their patients.
One approach to the problem of basic health care
for rural women is the African-style “maternitv
village”. This is situated near a hospital or health
centre, and a woman, following outpatient antenatal
care, arrives prior to her confinement with her
relatives who remain nearby to cook and care for
her. Delivery and postnatal care is usually provided
by supervised auxiliaries. Correct infant feeding and
the care of children under five are emphasized in the
educational measures in which the mother and her
relatives participate.
The Nigerian-style “under-fives” clinic is a further,
particularly sensitive, approach to the realities of the
role of rural women.
“A whole day wasted waiting in the (average) clinic
can ill be spared by the African mother who is a
busy woman . . . with a large family, food to grow, a
husband to cook for and, only too often, her own
living to earn . . . if she keeps her own child’s record
card, she need not waste time waiting for the clerk
to find it . . . nor need she wait at the dispensary if
the nurses keep medicines on their tables”.29
In their role as wives and mothers, the influence of
women on family health is critical. They frequently
have the power to reinforce - or sabotage measures designed to improve community health.
For example, the maintenance of latrines and wells
often falls to them, and without their comprehension and support of these innovations, the unkept
latrines and polluted ~IEIIS instead become health
In a comprehensive community approach, the role
of women in rural health is not seen as one merely
of passive enlightenment
and mute support of
others. Rather, in the industrious round of domestic
and communal activities, a new more dynamic role
emerges. (A minority will eventually assume more
technical and bureaucratic roles). What is sought is
the self-development of rural women. But the low
status of women is seen in some quarters as a
hindrance to the attainment of this new role.
However, estimates of status must be appreciated
within their cultural context. The rural woman has
many traditional
and prestigious responsibilities
both inside and outside her home, and weeding,
pounding and water carrying are not merely manual
labour. In some societies, women’s status has altered
as sociocultural change has occurred as, for example,
in Zulu society, where the absence of the menfolk as
migrant labourers necessitated the caring for cattle,
a strictly
male pursuit,
by the
The task of communicating with rural women is
complicated by their often “enclosed” status which
may necessitate making the first contact via their
husbands or mothers-in-law. Once trained for health
activities, women have been found to be particularly
beneficial frontline workers in any pattern of basic
health services. Their advice is readily acceptable in
the community and they can easily adapt their
approach tcr the local social, religious and cultural
attitudes.30 They are also more “rooted”
in the
often for domestic reasons, and less
likely to leave in pursuit of better employment.
It incorporates ongoing Research and Evaluation
11. Research and elialuation are considered an
integral part of the approach. The importance of
education is emphasized, and changes in attitude are
considered as of similar and, on occasion, of greater
significance than material changes.
A physician engaged in rural health in the
Philippines called research “a basic tool to reorient
and reformulate community medicine to meet the
needs of the people ” .31 The treatment of the
patient can be monitored, treatment
modified accordingly and the information gained
used to enrich future treatment.
The value of research during or following health
activities is commoner than that prio,. to their
commencement. “There is usual” a greater demand
for data after a project COI ,- to an end . . .
headquarters and supporting organlz:Qions want to
know what they got for their money”.3Z But
“baseline” and “pilot” studies may well be crucial
to eventual success. For example, if research had
been carried out prior to the inauguration of an
unsuccessful health insurance scheme for rural
families, it would have emerged that the modest
premium required was even then too large for the
impoverished families to pay.
Much research of value for health lies strewn
many other fields, such as, for
example, agriculture, education, anthropology and
nutrition. Much data of importance for health deals
with private thoughts, behaviour and attitudes.
These things are hard to elicit and even harder to
quantify. Research in community health is particularly difficult in that it often requires a range of skill
and personnel which reach beyopd those of health
Past research has often been based on personal
observation or isolated small-scale studies from
which it is hard to generalize. One problem is that
research among those who attend as patients is not
representative of the whole community, many of
whom do not attend at all. In the words of a
physician in a part of rural India: “There must have
been 4000 deliveries each year, but we were taking
care of only 300 of them. What happened to the
3700 deliveries?
cam for care, 20 remained
For every patient that
in the village.“33
For over Norked health personn,, research often
rf?pESen~ an output of time and energy which they
find themselves unable, and often unwilling, to give.
Some countries have enlisted the help of auxiliaries
as the
Of StatiStks.
BUt statistics
and tables
can 1~11only a Part of the story of development. The
self-respect and self-reliance that village people gain
wnmt easily be measured. Rut these changes are
what make future Progress possible.34 Evaluation
to be effective,
should be determined at
the planning stages of health activities and proceed
during their duration.
The evaluation of health personnel themselves is not
usually carried out. Reasms for the success or
Of Particular
workers and projects
are not
always evaluated. In the past, “preoccupation with
keeping services going often prevented an evaluation
of tiere one was going”.35
Research and evaluation of health activities is crucial
in most countries. Appraisal includes whether
objectives are ping achieved at lowest possible cost
and whether the benefits accruing are recognized as
being greater than the cost.36
some doctors and nurses that public health is
secondary to hospital medical care, and training
professionals is more important
than training
sub-professional health leaders . . . (These attitudes)
are as difficult to change as traditional health beliefs
because of their cultural and psychological aspects”Y
And the traditional physician is warned against the
temptations of tacking “a little public health on to
his traditional
medicines. This can quiet any
haunting concern that he may not be doing enough,
and sti!l allow him to continue pretty much as he
was” .38
In the words of the same director of a Korean rural
health project “there should be a way to deliver the
fruits of Western medicine without the burden of its
In view of the fact that present approaches to rural
health problems do not appear to be adequate, a
comprehensive community approach perhaps poses
an economic and effective alternative.
1. WHO, “Report on Health Education”,
Series 89, WHO, Geneva, 1954.
From the common thread of past and present
[email protected] in rural health activities has evolved the
concept and methodology
of a “comprehensive
community approach”. This approach is particularly
economid in that it emphasizes the use of existing
resources, auxiliary
personnel and
appropriate technology.
Where it has been employed, albeit partially, this
type of approach has emerged as particularly
effective with regard to the achievement of both
short- and long-term objectives, integrated development, the avoidance of community disruption and
in PWllOting the self-development of individuals.
For, in the past, where communities have succeeded
in a~aining improved health, little self-growth has
occurred. They have neither increased in self-knowledge nor in ability for self-organization
Where a community WProach does form part of the
training Curriculum of health personnel, too often it
consists only of a few lectures i e a fragment of
the whole potential approach. ‘To ie effective, the
Principles and methodology of the approach require
to suffuse the whole training of health personnel
and allied workers, of all categories.
“Despite current emphasis on community
and the need for training sub-professional personnel
in developing areas, there still exists a feeling among
WHO, “Training
of the Public”,
Technical Report
of Health Personnel in Health Education
TRS 156, WHO, Geneva, 1958.
Koje Do Project,
3. J.R. Sibley, “The
Problems”, CONTACT
No. 5, Christian
mission, Geneva, Oct. 1971.
4. OXFAM, “Integral Health Programme of
Nicaragua”, OXFAM, UK. iunpublished
1973, p. 3.
Progress and
Medical ComRural Zelaya,
Report). Feb.
5. Halfdan Mahler, “An Integral Component
of SocioEconomic Development”,
Supplement fo International
Journal of Health Education, Vol. 16, No. 3, entitled
of the Eighth International
1973, pp. 5-6.
6. W. Oglonwu, “Socio-psychological
Factors in Health
an Experimental
Study on Methods and
In tern 9tional Journal
of Health
Education Vol. 16, No. 1, January 1973.
7. M. King, “The New Priorities in Tropical Medicine”,
for World Health, G. Wolstenholme
M. O’Connor (eds.), J.A. Churchill Ltd., London, 1971,
pp. 25-46.
8. W.H. Le Riche, “World Incidence and Prevalence of the
Major Communicable
Diseases”, Health of Mankind, G.
& M. O’Connor (eds.), J.A. Churchill
Ltd., London, 1967, pp. l-50.
9. J. Bryant, Health and the Developing World, Cornell
University Press, Ithaca and London, 1969, pp. 39-40.
10. F. Mahoney, “Anthropology
and Public Health”, South
Pacific Commission Ouarterly Bulletin Vol. 9, No. 4,
Noumea, S. Pacific, 1957.
op cit. (ref. 10).
12. J. Bryant, op cit. (ref. 9) pp. 4749,129.
13. M. King, Medical Care in Developing Countries, Oxford
University Press, Nairobi, London, 1966, Chap. 3: 15.
14. R.S. Arole & M. Arole, “Comprehensive
Rural Health
Project, Jamkhed”,
Journal of the Christian Medical
India, Vol. 47, No. 4, 1972. pp. 177-80.
And document
of same title in CONTACT
No. 10,
Christian Medical Commission, Geneva, 1972. p. 5.
15. J. Bryant, op cit. (ref. 9). pp. 141-2.
16. Personal communication,
17. H. Mu&em,
“The Nurse’s Role in Policy Making and
Jan./Feb. 1973, pp. 9-l 1.
18. M. King,op
cit. (ref. 13). Chap. 7:6.
R.S. Arole & M. Arols, op tit
(ref. 14).
20. 0. Lewis, “Medicine and Politics in a Mexican Village”,
Health CWrure and Community,
B.D. Paul, Russel Sage
Foundation, New York, 1979, p. 433.
21. M. Clark,
Health in Me Mexican American
of California
Press, Berkeley,
22. M. Mariott, “Western Medicine in a Village of Northern
India” in D.B. Paul, Healrh, Culrufe and Community,
Russell Sage Foundation, New York, 1969, pp. 23968.
23. R.S. Arole & M. Arole, op cit. (ref. 14).
24. F.T. Sai, et
Health and
No. 1,1972.
al, “The Danfa Ghana Comprehensive Rural
Family Planning Project - a Community
and A.J. Neumann, et al, “Danfa,
Ghana Medical Journal Vol. 2.
pp. 9-24.
25. M. Santiago, “The Paramedical Training
Impacr, September 1972, pp. 398-l 1.
26. OXFAM,
in Davao City”,
op cir. (ref. 4).
27. G. Foster, “Problems in Intercultural
Health Programs”,
Social Science Research Council Pamphlet No. 12, New
York, 1958.
28. G.W. Kafuko, “Organization
of Health Services with
Limited Professional Manpower”,
M. Prywes & A.M.
Davies (eds.), Health Problems in Developing Stares,
Grune & Stratton, New York, 1967, p. 168.
29. D. Morley, “The Under-Fives’
(ref. 13j, Chap. 6:6.
30. J. KarefaSmart,
“Health and Manpower”,
A.M. Daviesopcir.
(ref. 28j, pp. 266-77.
M. King, op cit.
M. Prywes &
31. F.S. Solon, “Rural Internship in Community Medicine”,
Sent0 Tomes Journal of Medicine Vol. 25, No. 4,
Manila, 1970, pp. 2679.
32. S.R. Hayes, “Measuring
the Results of Development
Projects”, UNESCO, Paris, 1959.
33. R.S. Arole & M. Arole, opcir.
(ref. 141, p. 1.
34. Commrrnity
Progress for C.D. in Mexico - Statistical Highlights”,
New York, 1968, p. 56.
35. J.H. Hellberg, “Some Thoughts on Health Planning in
Commission, Geneva, 1972. pp. 5-6.
36. S.R. Hayes, op cit. (ref. 321, p. 24.
37. H. Mussalem, op cit. (ref. 17).
38. J.R. Sibley, op tit
(ref. 31, p. 4.
Mary Racelis Hollnsteiner
(This is an edited version of the original)
Although people’s participation in affairs governing
their lives dates back to the beginnings of human
society, the concept has taken on a new significance
as societies have grown in size and complexity. This
is partly because the governance or management of
large groups has become more and more a
specialized enterprise, an area for “technocrats”,
trained bureaucrats, and well-educated political
leaders to handle.
One need not look too hard to realize that
differential access to economic resources generally
parallels power-holding disparities. Those persons
imbued with this awareness diverge
nonetheless in preferred strategies tor redressing the
One group focuses on immediate gains and
advocates open confrontation
of the powerful by
the powerless through a multitude of tactics and
strategies. This is accomplished by the latter’s
banding together and, in so doing, generating
collective power through mass action. This militant
approach forces negotiation on an equal bargaining
basis and promotes immediate, specific gains for the
poor and powerless.
Catering simultaneously
to general and specific
vested interests, these “modernistic” elites seize the
initiative to plan policy and implement programmes
for society. Although
they verbally advocate
people’s participation, in practice they bring them
into the picture only after the major decisions have
been made. Hence they often leave the ordinary
citizen, the grassroots population, the man in the
street, the proletariat, the masses - all equivalent
definitions of “people” as used here - to follow
their predetermined paths. If a path is crooked
where it should be straight, or straight where it
should be crooked, the people have little recourse.
They must accommodate to the preordained design.
Even if the blueprint is inappropriate to their needs
and aspirations, they are expected to conform. The
results range from submissive apathy to violent
A second group dismisses such an approach as
merely palliative, seeing even hard-won gains as
temporary delusions that lull the powerless into
continuing acceptance of distorted social structures.
In reality, argues this group, these partial victories
only deter the powerless from facing the real and
ultimate issue, namely, the need to overturn and
rtdamp societai struc::!res totally and campletejy,
if necessary, so that the distinction
between powerful and powerless is forever eradicated.
It is this perceived discrepancy between the more
oriented actions of planners and
administrators, on the one hand, and the particularistic preferences of ordinary people in complex
large-scale societies, on the other, that has led to the
emergence of people’s participation
as a controversial sociopolitical issue. From there, it is but one
more step to confronting the issue of power and
here it is lodged.
This article addresses people power from the first
group’s point of view, avoiding judgements on the
validity of the second. It deliberately selects from
among the many possibilities for enhancing the poor
majority’s participation in developing societies. The
particular aspect of people’s involvement in the
ptanning and implementation of human settlements,
specifically housing and community management
makes up the focus of this paper.
The rationale behind people’s helping to formulate
the kinds of homes and communities in which they
will live goes beyond a simple reference to
people in the
decisions that affect their own lives is significant for
several reasons.
A sense of responsibility
through direct involvement
First, programme results are more successful if the
intended beneficiaries take part in their design and
Moreover, if people like living in their community,
they will more readily take care of it and express
their interest in action. If uncollected garbage draws
flies, o. canals become clogged and overflow, or if
dirt pathways become ankle-deep mud sloughs in
the rainy season, they will likely do something to
remedy the situation, from complaining to the
Department of Sanitation to dredging canals and
filling in the rutted, muddy pathways themselves. If
a sense of friendly neighbouring has emerged, they
will help e needy neighbour out with the children
when she is sick, or go out of their way to tell her
husband to follow up a promising job opening. By
getting people involved in a neighbourhood building
or renewal project before actual work starts, the
ensure a better fit between people
and community.
of planners’ misconceptions
A second reason for people’s participation
is the
it gives architects,
planners, and
administrators directly involved in the project. By
showing them another perspective on the matter
under study, lowincome
groups can give their
middle- and upper-class counterparts new insights
into the ways of their clientele. The product of
years of technical training - the specialist - has
probably lost his capacity to empathize with
lower-income people’s viewpoints. Not only was he
never a member of the lower class; school curricula,
especially if he comes from a developing society,
have probably further alienated him from them. Nor
has he ever taken a behavioural science course that
might make him more sensitive to people’s values or
social patterns.
This combination of circumstances, therefore,
probably left him with little appreciation
lower-class people’s outlooks.
People’s participation thus
by making it possible for
technicians/managers what
not. It is a wise listener
seriously and revises plans
rectifies planning errors
clients to point out to
will work and what will
who takes these points
and programmes accord-
General increase in communitv’s
A third benefit of people’s participation
from the very process itself. For if it is genuinely
mass-based, it builds up the self-enabling character
and cooperative spirit of the community. Facing
common problems as a group in solidarity and finding
solutions collectively leads to greater self-assurance
and pride in the group’s ability to act productively.
Consciousness of a larger whole whose welfare is
every individual’s concern is more likely to evolve in
organized participating groups. While conflict within
is also unavoidable, it can, if handled properly, be
turned into a strengthening
device and yield
effective results.
Further, when people learn to operate and even
the institutions
of modern urban
society, to interact as peers with its technicians,
managers, and government officials, and to grapple
with technological problems and complex bureaucratic structures, they grow as individuals and learn
to cope with modern urban life. Successful
adaptation depends in large measure on one’s belief
that one can manage one’s environment, and on the
evidence that proves that one is indeed doing so.
Finally, people’s participation
springs from guarantees cited in most national constitutions of the
world. The right of citizens to express their views
and share especially in decisions that affect them is
the mark of a modern society. That ordinary people
are poor and often powerless does not mean they
need be voiceless. Since most nations espouse the
republican principle leaving sovereignty vested in the
people, it should not be difficult for private and
public authorities to give the people their just due.
Considering the number of valid reasons that can be
advanced for fostering people’s participation in the
and management of
human settlements, why are people not brought into
the picture as often as they might be? Or, put
another way, why is popular participation often
resisted by or even denied by the planner
One can suggest several
Conviction that the elite specialist knows best
Perhaps the major one is that the elite specialist
believes that, where technical
concerned, he knows best. In his view, a professional
education and degree equip and entitle him to make
the decisions. It is only a small step from “knowing
best” to “knowing what is best for them”, especially
when “them” represents barely literate people who
cannot tell a building blueprint from a flow chart. In
less-developed countries especially, where advanced
education is at a premium, specialists are so
accustomed to telling others less trained then they
what to do, that they find it virtually impossible to
accept as valid the practice of listening seriously to
the views of lower-status persons, particularly
contrary views. The fact of the people’s being the
end users and having ideas based on practical
realities carries little weight. Education, status and
income differences evidently
authorize a dual
The higher-status “experts” thus set the framework
of the discussion and carry it through in categories
meaningful to themselves but often incomprehensible to ordinary lay people, poor and lowly-educated as they are. Even if the latter should, by some
chance, have access to the neighbourhood plan for
comment, their non-participation
in earlier phases
renders it extremely difficult for them to understand the conceptualization,
much less to argue on
an equal plane in favour of any divergent view.
Generally embarrassed by lack of education Ix:fore
such prestigious personages, lower-status c: ,-izens
lapse into silent acquiescence. If their suggesti? or
arguments are demolished by the specialists, Their
is complete. The paternalis::<: or
even superior attitude of the specialist tolziards
ordinary people serves to convince the specialis: that
he must talk while they must listen. No gecluine
participation is possible under such circumst.:nces.
Apathy after years of powerlessness
Yet the reluctance or outright refusal of el’:;rs to
encourage meaningful people’s involvement 6:annot
be blamed wholly on any particular elite g: cup’s
actions. Part of the proiilem lies in the t:ieople
themselves. Years, indeed centuries in some ca:es, of
being planned fur have rendered them apathetic about
taking a hand in matters beyond their imnlediate
family domain. On the other hand, a pattern of
community participation does exist, but it revolves
around the observance of traditional rituals such as
religious festivals or wedding celebrations. Redirecting people’s efforts to the level and type of active
secular participation that housing and settlements’
development requires, poses a special problem. It
entails defining a new role for them in the daily round
of life.
Often outsiders, such as social workers or
community organizers, help people delineate the
issues that need organization and action. AltemaLivaly, people can be forced into a position of
aroused consciousness through a recalcitrant housing
manager.. High-handedness, arrogance, or sheer
inefficiency on his part can do the trick better than
any earnest social worker can. For the most part,
however, people forfeit any claims to participation
by apathetically
letting the specialists decide for
them. Experience has not led them to believe that
anything else is possible or feasible.
Government resistance due to fear of delays and of
While apathy about self-help in the context of
human settlements’ management probably characterizes the majority of .prospective residents in
countries, there are a number of
militantly organized people’s groups who not only
take the initiative to define their wants, but actually
demand participation. The organized shanty-dwellers who invade unoccupied lands and turn them
into dwelling sites in various Latin American
countries provide such an example. Often at a loss
to counteract such moves, some governments have
simply conceded to their de facto occupancy and
have subsequently
provided sites and services
components. A similar case in Tondo, Manila,
provides a counterpart Asian experience. One can
predict that, given the conscious articulation by
agencies and others of people’s
participation as a new ideal, more and more people’s
groups will find a legitimization of their conviction
that, when other conciliatory
mechanisms have
failed, open confrontation
and a demand for
negotiation is the only avenue left to them.
Herein lies an inherent contradiction in governmental espousal of people’s partici,pation, for once
grassroots awareness is aroused and people demand a
say in housing and community actions, government
may eventually find itself sending out police to
control angry demonstrators. Charges of subversion
may be levied and gaol terms meted out to offenders
who go beyond the government’s definition
legitimate participation. Unfortunately, the designation of the legitimacy/non-legitimacy
line remains
an ambivalent product of differential
where government and militant people’s groups are
concerned. Even if this extreme level of violence is
not reached, planners/administrators/managers
approach people’s participation with some reluctance.
They fear it will lead to delays in implementation
because an array of contradictory recommendations
will have to be reconciled.
A number of modes exist whereby people may join
in the
developing of housing and housing estates. Six are
delineated here. They are by no means the only
ones, but they do constitute some major types. One
can assess them in terms of: 1. the type of
pz;lticipation; 2. its functions; and 3. the locus of
power. The closer people come to co ;olling their
own life situations, the more fully participatory
they may be adjudged.
1. Unofficial
representation by a “solid citizen”
group which endorses outside-planned programmes
The first mode involves the educated “solid-citizen”
group as the key actors. They bear the brunt of
representing the people in dealing with government
or private development agencies. As prominent
people in the district
or in the community
undergoing change, their own educated backgrounds
render them acceptable to officials, as they tend to
share the same outlook and categories of thought.
Further, they possess a certain amount of influence
in their own right and can rally support for projects
needing it. Generally enthusiastic and sincere !n
their commitment to improving neighbourhood life,
they take the position of speaking for the people in
the community and planning for them, whether the
people have given them that mandate or not. They
sit on the community council as symbols of civic
consciousness. Correspondingly, the ordinary people
are organized into associations where they serve as
followers to these upper- or middle-class leaders,
leaving to the latter the responsibilities of dealing
with outsiders, of raising funds, and initiating
action. Success is reckoned in terms of the number
of meetings held, projects launched in the
community, and material benefits resulting from
them. Since the leadership is of a voluntary nature,
these leaders must exert a great deal of energy and
personal magnetism in order to get people to
provide a mass base of support.
This mode of participation, so typical of Filipino
towns, has the function of legitimizing outsideplanned programmes by having prominent local
elites endorse the activities offered and play key
roles in them. An assessment in terms of grassroots
participation would have to conclude that, under
this mode, the locus of power remains at local elite
levels. The grassroots sector plays only a minor, if
any, role in decision making; the function allocated
to them is to follow and to serve as a population
needing help.
2. Appointment
of local leaders to positions
government bureaucracy
The second mode of participation
appointed local leaders in the government bureall
cracy as representatives of the people. They may
consist of ward leaders, or community relations
officers, or neighbourhood
chairmen. As local
residents, they take the lead in bringing government
and civic agency programmes down to the grassroots
level, interpreting for the people what is to be done
and how it should be done. Their acquaintance with
procedures and prominent
enables them to accomplish activities requiring
agency assistance and influence. At the same time,
their authority enables them to mobilize groups of
people for all sorts of events: to march in civic
parades and wave flags on national holidays, to serve
as audiences for political leaders or other speech
makers, or to join work brigades for widening streets
or cleaning canals.
These officially or semi-officially appointed bureaucrats serve to legitimize programmes drawn up
outside the community, be it a cleanliness drive, a rice
distribution scheme, or a lottery to determine the
choice of dwellings. Moreover, their authority allows
them to direct neighbourhood activities and perform
as spokesmen to higher authorities. With the locus
of power residing in these lower-level bureaucrats,
grassroots citizens find themselves far removed
from decision making even if they participate by
choice or otherwise in the community activities
des’gned for them. Direct sharing on the part of the
population in the plan formulation and management
remains virtually
nil, even though a kind of
evolves through their followership
3. Community’s choice of final plan from among
predetermined options
The third mode entails ex post facto consultation by
development personnel with the people at the
community level. The classic situation occurs where
a development agency is upgrading or renewing a
or building
a new
relocation site to house a specific evicted population. Here architects, economists, engineers, and the
like spend months drawing up plans for community
layouts and job creation. When the plans, or one
phase of them, are completed, these technocrats
then call a meeting with the community to explain
the plans and solicit its views.
In terms of people’s participation, this mode comes
closer to the mark than the first two since the
actively enters into the
grassroots population
picture, making up the majority of participants.
Moreover, people do have a say in telling the
planners whether or not they like the designs or job
creation schemes or neighbourhood rules laid out
for them. Full-scale participation
is nonetheless
wanting in this situation since the options have
already been predetermined by others. Nor are the
assumptions behind the scheme always clear to the
people, since they did not go through the same
process as the designers/planners in considering a
wide range of possibilities and rejecting some in
favour of others. Consequently, the people are
offered Plan A, Plan B, and Plan C, and asked to
choose among them. This is accompanied by the
presentation of mzps, charts, and diagrams in
confusing succession. Plan A and C usually turn out
to be mere variations of Plan B. As a people’s
planner once remarked, “Belive me, it’s always Plan
B that bureaucracy
planners want people to
‘choose’.” Since Plan A approximates the people’s
interests more closely and Plan C is the technocrats’
ideal, Plan B usually wins the day because it
represents the compromise that presupposes ha-’
many and cooperation from then on. Thus, the ex
post facto mode of participation does see people
in community
decisions, but on a
token basis more than
have been devised long
The people are merely
suggest minor revisions
outlines of the scheme.
ing consultation
on a real one. For the plans
before the first consultation.
expected to endorse them or
without changing the basic
starting with plan formula-
A significant breakthrough comes about in the
fourth mode of participation, namely, consultation
between people and planners right from the
beginning of the plan formulation.
The very
ordinary people sitting in and expressing their
opinions. To facilitate discussion, their elected or
chosen leaders meet with planners more frequently
and regularly, with community
assemblies held
every so often for wider dissemination of information and discussion. These sporadic meetings allow a
two-way communication
process; the people are
kept abreast of developments to date, and at the
same time check the directions their leaders are
taking in representing their interests. Since no
community is homogeneous, the varying views and
interests of the population
emerge in such
gatherings, dramatizing
a range of sometimes
conflicting interests which the chosen leaders must
end work by famil
in lowcoat
housing nconstructian
Early involvement in the planning process not only
leads to a more suitable outcome for those who are
most affected; it also gives people an appreciation of
the complexity of the process and an awareness that
issues are rarely simple and clear-cut.
5. People’s
The fifth and sixth modes of participation have
people’s chosen representatives actually serving on
decision-making boards. In the first case, the people
of a housing community, for example, have one or
two representatives sitting on the board to express
their interests and viewpoints; in the second, the
board is, in effect a people’s board because the
majority of members on it come from the grassroots
6. Community
control over expenditure
of funds
The sixth mode marks the triumph of people’s
in that the grassroots elements
dominate the membership of the decision-making
board. The expenditure of funds falls completely
meaning that they allounder their control,
cate it according to a scheme suited to the
people’s wishes. Even here, of course, their
independence is not total, since the funds come to
them from higher levels of government or from
agencies. Hence, negotiations with
project int Slkwty,
on the frinp
of Guatemala City.
these entities remail necessary, but usually On a
per basis. For the aim of people’s participation is
not to divorce people’s groups from the state Or
centres of SOCietY as a whole.
Rather, in human settlements’ development, it iS t0
give the ordinary residents a significant voice in that
A summary prf%entatiOn Of the six modes described
here appears in the following pradigm.
One must
remember that some overlapping Of modes may
occur at different community levels.
Modasof People’sParticipation in the Planning and Managementof Human Sgttlamants
LOCMSof power
Agssment in terms of
direct exercise of power
by the people
“Solid citizen” educated
group appointed by
outside authorities
Planners and local elites
Legitimizes outsideplanned programmes
through endorsement and
via local
People are minimally involved,
if at all, in decision making
Appointed local leaders
in the government
Planners and local elites
Legitimizes outsideplanned programmes
through endorsement and
via local
elites; facilitdtes implementation of outside programmes, since local elites
have authority from above
People are minimally involved in decision making,
although the official character
of leaders’ authority encourages people to join in programme
activities as followers of recipients of the benefits entailed
Planners in ex post facto
consultation with people’s
Planners; people to a
slight degree
Legitimizes outside
planned nrogrammes by
having people feel they
have a say in matters
affecting them; allows
some feedback from people
on their views about plans
People’s involvement in discussion of plans after they have
been formulated alfows few
genuine options; participation
exists but only in token
Planners in consultation
with people’s groups from
the beginning of plan
Planners and people, but
planners have more
authority than the people
Allows a meeting of minds
and views between planners
and people; gives people a
more realistic understanding of planning process and
need to establish priorities
People’s involvement in the
formulation of plans and in the
manner of their ~mplcmentation
gives them a sigificant share in
decision making; however,
planners still control the process
People have one or two
minority representatives
on a decision-making board
and people, but planners/
administrators have major
decision-making power as
the majority membership
Legitimizes the concept of
people formally having a
voice in local affairs through
direct participation
representative vote; also
legitimizes boards with outside elite in control
People’s participation
significant because they share in
decision making by having an
official vote on a local governing
People have the majority
representation on a decision
ma king board
People and planners/
administrators, but people
have major decision-making
power as the majority
Legitrmizes the concept of
people’s having the dominant voice in local affairs
through direct participation,
control of votes, selection
of technicians/planners
assist them as advocates
People have attained full participation in controlling the actions
of the official decision-making
of participants
Further, the strength of a community is Ii kely to be
greater, the more closely it approximates those
modes nearer number 6 than number 1.
It is evident from the discussion summarized by the
paradigm that the six modes of participation reflect
three basic approaches, namely:
a) local elite decision making (modes 1 and 2);
b) people acting in an advisory capacity to elites in
authority (modes 3 and 4);
c) people sharing in, or contrnlling, local political
decisions affecting their lives (modes 5 and 6).
Two divergent orientations to the causes of poverty
apply to the choice of any particular mode. Where
poverty is believed to be the product of individual
disadvantages or deficiencies, action programmes
focus on changing people so they can function more
effectively in society. Hence, providing them with
improved social services is deemed to be the solution
to helping them compete more effectively in the
larger society. Having obtained these benefits, they
presumably can cast aside their poverty and achieve
a decent level of living.1
Here lies the rationale behind modes 1 and 2,
namely, the emphasis on providing assistance and
benefits to enable people to live better lives. It is the
basis of the community
development approach
espoused by private and public welfare-oriented
agencies in which harmonious cooperation is the
dominant ethic. Self-help, it is believed, will arise
out of people’s raising their incomes through joining
personnel training programmes or making available
limited amounts of credit for small-scale enterpreneurial operations. Their common welfare will grow
out of community
councils organized by social
workers to channel the flow of goods and services
from the larger society into the community. These
arrangements may indeed lead to somewhat mere
prosperous communities, but they do not challenge
Instead they accept the
the basic structure.
prevailing principle of elite control.
The second orientation
explains poverty as a
product of social and economic systems that remain
intact precisely because of the “powerlessness of the
poor and the dominance of the wealthy powerholders”. In this view, only as the poor acquire
political power can they negotiate as peers with
their wealthier counterparts and themselves change
community policies and conditions inimical to their
state. Modes 5 and 6 best express this policy-making
The transitional situation represented by modes 3
and 4 combines the two extremes in espousing the
community development approach with incipient
versions of the grassroots-policy-making one. While
often difficult for elites to accept, it nonetheless
represents the position currently taken by more
progressive agencies. The object of far greater
resistance among authorities the world over is the
political power orientation
advocated by a few
organized people’s groups. For, aside
from being a nuisance or a downright threat to
beleaguered groups in authority, they give rise to a
over whether the government or
established private agencies can or should subsidize
with funds or otherwise support citizen groups
apparently in open opposition to duly constituted
authority. From the people power point of view,
however, this confrontation stance has proven to be
the only really effective means of jolting slowmoving bureaucracies out of their lethargy and
forcing them to take seriously conditions adversely
affecting the everyday well-being of the people.
Since the role of government is to serve the
people, they say, these active grassroots groups
and their supporters feel their conflict strategies and
political goals need no further justification.
When people and planners/administrators/managers
deal with one another, each set uses a range of
strategies to achieve its objectives. If a particular
people’s strategy works, and the other party accepts
it, the users come away satisfied; a period of relative
quiet and perhaps even harmony prevails. If it does
not work, either apathy or a stronger approach is
mc*,-ted on the people’s part. The development
per,... .nel, on the other hand, may opt for
approaches, bureaucratic inertia, or
more authoritarian tactics.
The issues, then, come down to how far organized
people power and its strategy of confrontation can
be tolerated by government, and to what extent
forms of people’s participation may be acceptc2d as
legitimate by law enforcers. Where is the line to be
drawn between legitimate representation by people
of their collective desires, on the one hand, and.
outright defiance of government authority, on [email protected]
other? Certainly, most people and government
officials seek and prefer peaceful means of attaining
their own ends. But each set can be pushed only so
far before it turns to more violent responses deemed
justifiable under the circumstances.
People can pa;ticipate effectively in the management of their own surroundings only if they have
developed a sense of community and have organized
themselves into associations. This exp!ains why a
grouping of new residents ilvho did not know one
another previously proves difficult to organize. It
takes time for people to feel at ease with one
another and to accumulate the experience of
interaction that allows some assessment of what the
others are like.
Creating opportunities
for contact
The process of breaking down barriers and
establishing a modicum of trust can be accelerated,
however, by creating opportunities for people to
come into contact with one another. Recreational
programmes geared to the children will often bring
out even the most aloof householder. Mothers’
classes in nutrition
or income-raising activities,
carpentry seminars, or, in rural settlements, farmers’
meetings for the men, help cement new-found
even as they communicate
knowledge to the participants.
Given the dearth of formal associations in
settlements composed of residents who moved in
almost simultaneously or in waves some months
apart, it may be necessary to have professional social
workers or community organizers deliberately set
about forming the people into organizations, usually
on a block basis. Yet one should also be aware that
evidence from rural and urban settings the world
over suggests that. grassroots organizations founded
and nurtured by the government rarely succeed in
becoming effective means for people to express
themselves. Privately-organized spontaneous efforts
do much better. In view of this, it would be well for
the above-mentioned
social workers to phase
themselves out as soon as possible.
In older communities which are being upgraded, one
can reasonably assume that a wide variety of formal
and informal groupings already exists. These can
become the basis of a larger umbrella organization
made up of groups who formally file an application
to join. If representation on a block basis is also
necessary, the existing organizations may plan out
the new structure. Whatever the final composition
of the community grouping, its existence as a truly
representative body is crucial for effective people’s
participation in the management of their settlement.
An organized community group performs several
important functions. They may plan and implement
numerous projects, especially if they have access to
funds. They make it easier for outside agencies to
help community
programmes as they provide a
formal organization with which an agency can deal
they can hire and direct
technicians to carry out their own plans. All these
functions have great potential for the independent
action of the community group.
Too often, it is assumed that the training
of a housing and neighbourhood
settlement falls completely on the residents. Yet,
because of the often wide gulf between the people
of low-income communities, and elite managers, the
latter need just as much of an education, but of a
different sort.
Educating mana
ment personnel :
1. A better understanding of the conditions
life-style of the urban poor.
The greatest deficiency found in management
persontlel is their general lack of understanding of
low-income people’s life-styles, outlooks, and
aspirations. They tend to censure the residents
basically for not being or thinking like themselves. The precariousness of the household
economy among the poor is something most
middle-class specialists cannot sufficiently appreciate. They will thus deplore, for example, a
family’s turning to scavenging and littering its
immediate surroundings with discarded paper,
plastic, metal, and glass bottles. The filth and
disarray offend their aesthetic sensibilities, even
as they assume that the ragpickers see nothing
disturbing about being dirty. A recent Manila
study has shown, however, that scavengers do not
enjoy their situation any more than anyone else
and would gladly leave that occupation if any
other viable opportunities
turned up.* Since
chances are limited, the scavenger accepts this
.form of income generation as tolerable; it is after
ajl better than theft or outright unemployment.
2. A service rather than a control orientation.
Attitude change on the part of the manager who
looks down on his customers is aiso called for. It
is difficult
to inculcate a service orientation
instead of the control orientation towards tenants
among long-time bureaucrats, used to taking a
superior attitude towards their clients. Appreciation of the rights of people, regardless of their social status in society, is a view that often
needs conscious learning among elites. Better
rapport with the people needs conscious reinforcement as well. So too must an understanding
be cultivated of conflict strategy in people’s
organizations and the possibility of negotiating
with them as peers.
3. An awareness of the social implications
of policy
Finally, an awareness of, and concern for, the
larger social implications of policy decisions needs
to be developed. Thus, the manager who believes
he is doing the community a favour by banning
street vendors or hawkers in the interests of order
may find that his decision
and sanitation
eliminares the incomes of 100 local breadwinners,
and therefore the source of livelihood
600 people, mostly children. Hunger, malnourishment, and sickness come in its wake, and he may
be forced to initiate costly welfare programmes to
enable this group to survive.
4. Training
courses for
How are these reformulations to be communicated to the manager ? A training seminar would
be a good start, Here, sociologists and anthropologists who have done research in comparable
can describe and analyze the
subculture of poverty. Psychologists can help the
managers understand the roots of their own
attitudes and conduct laboraton/ exercises in
group dynamics, role playing, simulation, and
games for behaviour change.
Panel discussions by the more articulate poor
residents focusing on their reactions to life in the
area under those particular circumstances can
communicate something about the rationality of
their outlooks. Tours of other communities which
have fairly successful people participation
housing decisions, and discussions with their
managers and people’s organization leaders, can
further drive horn2 the message as no amount of
lecturing can. Refresher courses with other estate
managers every few years enhance the good
beginning already made in learning the more
progressive approaches utilized by their advanced
colleagues. For those seeking genuine empathy
with t_hepeople they are to serve, actual residence
in the community
proves to be a particularly
enriching, if difficult, experience.
Educating the residents:
1. Training grassroots leaders in communication
urban planning.
Residents also profit from various kinds of
educational programmes. Community assemblies
that try to convey the ideas of the manager in a
consultative rather than commanding tone generate interest and understanding on the part of the
local grassroots leaders
usually proves a wise decision. Their ability to run
meetings so that everyone who wants it has a say,
without prolonging the gathering unnecessarily or
letting it get out of hand, is a necessary skill.
Further, if they learn some of the rudiments of
urban planning, management principles, and
architectural design, they can better appreciate
the constraints under which professionals in these
areas operate. Their all too obvious disadvantage
at meetings with these specialists becomes less
pronounced and their sense of inferiority
defensiveness diminishes as their command of the
subject matter increases. Thus, later discussions
with the managers will be conducted on a more
egalitarian basis, an experience which will stand
them in good stead should they actually take over
control of the housing estate and have to hire
their own supervisory and working personnel.
2. Training in technical
impro vemen t.
skills for neighbourhood
of the people involves not only
in decision-making procedures, but
also in the technical service needs of the
Ideally, residents should be given
hiring preference for local jobs.
It should by now be amply clear that if people do
not participate in the planning and management of
their immediate surroundings, the chances of their
improving, not deteriorating, drop
The areas of housing and estate
management offer natural incentives for encouraging
people to act in their own and their neighbours’
interests. After all, home snd family come closest to
a householder’s heart everywhere in the world.
educated elites make people’s
involvement difficult. They have been “experts” too
long to allow their pronouncements to be challenged
by near-illiterate, simple people. Theil values have
been nurtured on middle- and upper-class preferences for beauty, order, symmetry, and reliance on a
fat pocketbook for realizing their desires. Little
understanding the constraints ordinary rural or
urban dwellers face in choosing their life-styles and
residential locations, the technocrats draw plans
with a grand sweep but a myopic one vis-ti-vis the
interests of the poorer population.
Perhaps this technocratic approach has recently
served to generate people’s pa:.i’icipation. For it
ranks technical efficiency,
abstract design, and
high-level cost-benefit analyses, based on economid
assumptions often alien to the people’s real
situation, above basic human concerns. The latter
can include kinsmen wanting to be located near one
another despite a site-raffling plan, fear of losing
customers owing to the required transfer of a
household industry into a centrally-located manufacturing site, a resistance to sharing newly-built
toilet facilities with one’s neighbours, or insisting on
lot ownership even if leasehold constitutes the
experts’ preference.
Peattie has observed that, when politicians held
sway in less technologically complex times, people
could express their views on a more egalitarian basis
and expect some kind of sympathetic
response from
their non-technical
leaders.3 But in the
age of the technocrat,
mortals cannot
really meet him on his own terms. His knowledge is
too specialized for them to contradict on a scientific
or technical basis. Not even the politician-bureaucrat
can compete with his judgements. Thus, a growing
emerges among ordinary people that the
only way to make the technocrat scknowledge other
factors to which he has given little recognition thus
far is to smoke him out of his air-conditioned
and force him to see reality as it is lived. If he balks
- and he usually does at first since no one of lower
has ever challenged
him before - an
organized people’s group can restore the balance his
has tilted
in his favour.
The more
he becomes about having his way, the
more militant an opposing people’s group is likely to
become. The reaction of unorganized groups, on the
other hand, is an increased apathy.
In the long run, people’s participation
cannot be
For, through
in community
affairs, they
begin to learn what organization
and united action
can accomplish.
It will not take them much longer
to discover that, so long as basic institutions
society and the existing power distribution
do not
change, their situation
is not likely to improve
only quantitatively
at best. Thus, more
of free medicines will come to their
more lower-level
jobs will be opened to
them, water will be piped into the houses, parks and
playgrounds will be improved - the list goes on and
on. Yet they remain at the bottom of the social
heap, moving up in small increments
perhaps, but
always overshadowed
by the ever-increasing
affluence of their countrymen
higher up on the scale.
Those who move up are, of course, the more
fortunate ones. The great majority remain right were
they are, beyond the reach of the trickle-down
process. When the total social structure undergoes a
can be
drastic reformulation
- which presumably
policy is assessed in terms of its human
ior the bottom
half of the
costs, especially
only then can a just society emerge.
dilemma. The housing manager may genuinely seek
the views of occupants;
but if basic differences
become irreconcilable,
he callnot condone
violent action on the people’s part. At what point
does he evict “undesirables”
and “trouble
who are arousing the population
against him in a
issue over the installation
of hallway
bulbs in a tenement,
or the revocation
of a bus
franchise to an outsider? At what point does he call
in the police if a sit-in or passive resistance tactic
has gone on too long, disrupting ongoing activities?
Who are “the people” in the first place? Which of
the competing groups in the community
should he
recognize, if any, as legitimate spokesmen?
It is easier to pose these question than to answer
them, partly because the world’s experience with
people power and participation
remains limited. The
elusive happy medium between apathetic people and
on the one hand, and
people coupled with repressive authorities,
on the other, is still being sought in country after
country. The more laudable models provide too few
examples. But the search must continue, for the age
of the comon man and the common woman is upon
us. They will not tolerate for long always taking the
role that poverty
has heretofore
not when the development
trumpets loudly its aim of enhancing the lot of the
masses and encouraging self-reliance.
So long as resources and power continue
to be
lodged in a few in this otherwise enlightened
the potential
for effective
grassroots movements
looms ever greater. Since elites seem loath to
or even share their
capacities with their poorer brothers and sisters, it is
safe to conclude that the struggle for people power
will dominate the close of the twentieth century.
1. Ralph M. Kramer, Participation
of the poor: comparative
case studies of the war on poverty, Preritice
Hall, Englewood, NJ., 1969.
2. Will iam J. Keyes, Maniia scavengers: the struggle for urban
survival, mimeographed
paper, Institute
of Philippine
Culture, Ateneo de Manila University, Quezon City, 1974.
3. Lisa
on advocacy
planning”, Journal of the American Institute of Planners
34, 1968, pp. 80-88.
view direct
in their own world?
Here lies a
D. Banerji
Health services are one of the many factors that
influence the health status of a population. Health
of a population is also influenced, sometimes even
more significantly,
by such social and economic
factors as nutrition, water supply, waste disposal,
housing, education, income and its distribution,
employment, communication and transport and the
social structure. Secondly, like the other factors
influencing health status, the health services of a
community are usually a function of its political
system Political forces play a dominant role in the
shaping of the health services of a community,
through decisions on resource allocation, manpower
policy, choice of technology and the degree to
which the health services are to be available and
accessible to the population, for instance.
These political dimensions of health services political economy of health - are brought into a
sharp focus by the cases described in the World
Health Organization publication,
Health by fhe
People.1 In countries such as China and Cuba, where
very positive efforts have been made to involve the
entire population in the process of decision making
as a part of a nation-wide political movement for
bringing about a radical social change, an alternative
perspective for rural development and, as one of its
components, an alternative health care system
developed as its logical corollary. In these countries,
the very process of bringing about democratization
of the political system had led to serious questioning
of the technological, social and economic bases of
the health care system which was prevailing earlier.
In the case of Tanzania, where serious attempts are
being made to promote democratization
at the
grassroots, the earlier health care system, which was
inherited from the colonial rulers, is being subjected
to a close scrutiny. This scrutiny has already led to
a shift in the allocation of resources from the urban
to the rural, from the curative to the preventive and
from the privileged class orientation of the services
to those which are oriented to the underpriviledged
In all these three instances, all the sections of the
community, particularly the weaker sections, have
been actively involved in the shaping of an alternative
primary health care service and in its implementation.
in countries where the process of
democratization has not made deeper inroads, there
is considerable hesitation and often confusion in the
formulation of alternative health care ,ystems. The
WHO publication describes two categories of cases.
One category is exemplified
by two oil-rich
countries. In both these countries, the political
system has not allowed any change in the highly
sophisticated, state-subsidized curative services in
urban areas which are accessible mnstly to the
privileged classes. However, both these countries
happen to have very dedicated Health Mininers. Even
within the very stifling political constraints, they have
been able to make significant innovations in the rural
health services of their countries. However, it is
be seen whether, within the existing political
climate, the alternatives promoted by these workers
will turn out to be viable ones.
Guatemala, Indonesia and India are in the other
category of country. In all these three countries, not
only has the process of democratization not reached
the underprivileged and the deprived sections of the
population to any extent, but there has also been a
conspicuous lack of leadership in the field of health
care. This might explain why, in all these cases,
inspiration for alternatives had been sought from the
experiences of Christian missionary organizations.
These experiences are derived from programmes
which had available to them disproportionately
amounts of resources (when compared to the very
small population served by them). Further, they had
workers who worked with a missionary zeal. These
certainly are not reproducible and they cannot be
considered as alternative health care systems for the
rural populations of these countries.
Formation of alternatives is thus essentially a
political question. A crucial determinant of the
nature of an alternative is whether there is a political
system which continues to encourage a country to
be ruled by an oligarchy or whether it actively
promotes a change in the social system which
enables the masses, particularly the underprivileged
and the under-served, to actively participate and to
have their say in the affairs of their country.
Under a political system which sustains the status
quo which perpetuates an oligarchy, alternative
systems are formulated either to find more effective
approaches to serve the ruling oligarchy or, much
worse, to provide on aura of legitimacy to an
obviously unjust social system by arousing false
hopes among the underprivileged and the underserved.
Development of super-specialities to provide services
which are Inostly accessible to the privileged classes
can be cited as an instance of an alternative health
care system within a political framework which
perpetuates an oligarchy. Establishment in poor
countries of Rotary Club-supported cancer haspitals, setting up of units for cardiothoracic surgery
and neurosurgery and other such super-specialities
and opening of elaborate intensive care units,
form the medical care components of alterna
tives under such political systems. Campaigns
for cancer control, development of genetic counselling services and control of noise pollution are
examples of components of preventive services of
such alternatives. Imposition of compulsory sterilization on the weaker sections of the population,
without making available to them even the most
elementary health care services and economic
security provides another facet of an alternative
within this political framework.
Efforts to cover up such obviously unjust and
inequitous distribution
of community
health resources in poor countries by projecting manifestly
unreplicable measures as miracle solutions of the
health problems of the masses in these countries
form an even more pernicious
category of
systems that are
dominated by an oligarchy. Work by a highly
respected clinician to develop “voluntary”
services in a periurban population
of a few
thousand with the help of heavy state subsidy,
heavily subsidized health insurance schemes to cover
some villages and state-subsidized health cooperatives to cover the medical needs of the “middle”
classes are instances of this category of “alternatives”.2 In recent years, a number of Christian
missionary institutions, which have extended their
“charitable” medical work from the hospital to the
community, have been projected with the help of a
well-orchestrated propaganda campaign as alternative health care systems.2 Here, again, adequate
consideration has not been given to their replicability in the rural population at large.
In their eagerness to find alternatives within the
existing political framework, unwittingly, or otherwise, research workers have lost sight of a most
glaring sociological characteristic of rural populations of the poorer countries : the acute stratification of such populations
into a small but
all-powerful oligarchy which has a stranglehold on
the vast masses of the dispossessed and the deprived
It has been assumed that such a
can select Its own health functionary,
its own “barefoot doctor”, and thus, it will be
possible to have an alternative of “health by the
people” as opposed to the earlier approach of
“health to the people”.
In a political system where there is a commitment to
extend the process of democratization and involve
the entire population
in decision making, the
circumstances for formulating an alternative health
care system are basically different. In the first place,
in such situations, there is considerable enthusiasm
among the people to actively participate in the
shaping of their health services system and in
actually running it. Secondly, the very process of
democratization ensures that those working at the
levels are impelled to evolve an
alternative technological framework which is more
meaningful to the entire population, particularly to
the weaker sections.
No doubt, more often than not, this commitment to
is used as a mere facade to
perpetuate the old, unjust, social relations. It is also
very likely that, under such political conditions,
of an alternative system, however
scientific and relevant, becomes at best a mere
academic exercise. Nonetheless, even an academic
exercise can become a useful instrument for putting
some pressure to bring about the desired political
change by offering
concrete, well-thought-out
alternatives. It can, in any case, serve as a blueprint
for action when the political changes finally take
Truly conforming to what Gunnar Myrdal has called
the “soft state” character of the Indian political
system, the political leadership of independent
India, while solemnly promising to make available
benefits of the health services to the masses,
to the weaker sections, not only
perpetuated the old colonial tradition of having an
urban, curative and privileged class orientation of
the health services. It also actively promoted such a
colonial outlook by making available disproportionately more hospital beds for urban populations,
by setting up more extensive facilities for superspecialities which are accessible mostly to the urban
population, by very rapidly expanding facilities for
Western-oriented medical education and by abolishing the old licentiate medical course.
Recommendations by the Bhore Committee (Health
Survey and Develcpment Committee),3 which was
set up by the colonial government of India in 1946,
provided an almost revolutionary alternative to the
then existing health care system of British India.
Apparently inspired by the Soviet Union and by the
welfare measures recommended by the Beveridge
Committee of the United Kingdom, the Bhore
Committee adopted the following as the guiding
principles for its recommendations:
no individual should fail to secure adequate
medical care because of inability to pay for it;
health progammes must, from the beginning,
lay special emphasis on preventive work;
the need is urgent for providing as much
medical and preventive care as possible to the
vast rural population of the country because
they received medical attention of most rneagre
description although they pay the heaviest toll
when the famine and pestilence sweeps through
the land; and,
(iv) the doctor of the future should be a social
physician attracting the people and guiding
them to healthier and happier life.
Significantly, way back in the thirties, the leadership
of the freedom movement in India had also accepted
similar guidelines for developing health services for
independent India. 4 The Report of the Bhore
Committee, which was submitted just on the eve of
Independence, should have provided a very valuable
draft blueprint for a new approach to health services
in India. In fact, the government of independent
India readily accepted the recommendations of the
Bhore Committee. However, apparently because of
the political orientation of the leadership, the key
of the Bhore Committee got
considerably diluted and there was considerable
delay in actually putting on the ground even those
diluted versions of the recommendations. Ironically
enough, the same political forces invoked the Bhore
Committee Report and the urgent health needs of
the “people of India” to perpetuate and actively
promote the colonial tradition of the urban, curative
and privileged class character of the health services
system of the country.
Only after 20 years of independence was it possible
to cover the rural population of the country by a
type of primary health centre which is manifestly
rudimentary and grossly inadequate, both in terms
of the quality of the services as well as coverage of
the population. 5 These primary health centres are a
very far cry from what was suggested by the Bhore
Committee: they did not have even a fourth of the
minimum requirements of the staff”
recommended by the Bhore Committee (and that
too as a short-term measure). During the same
period. spectacular progress was made in expanding
the medical education system of the country, with
expansfon of hospital facilities in urban areas, both
qualitatively as well as quantitatively.
Subsequently, some more efforts were made to
develop alernative health care systems for rural
In 1963, a Government of India
committee6 recommended that rural populations be
provided integrated health and family planning
services through male and female multipurpose
workers. But the clash of interests of malaria and
family planning campaigns soon led to the reversion
to unipurpose workers. In 1973, yet another
committee7 revived the idea of providing integrated
health and family
planning services through
multipurpose workers. This tirrre also, the prospect
of effective implementation of the scheme did not
appear to be very bright. Earlier, there had been at
least J\IO more efforts, both similarly abortive, to
develc t alternative
health strategies. One, the
so-cai .d “Master Plan of Health Services” envisaged,
(in 1 I 70) more incentives to physicians, establishment of 25bed hospitals and use of mobile
dispensaries for remote and difficult rural areas.*
The other,9 apparently inspired by the institution of
the “barefoot doctors” of China, was to mobilize an
estimated 2,000,OOO registered medical practitioners
of d”ferent
systems of medicine as “peasant
physb, ?ans” to serve as rural health workers.
BecaL e of this long neglect of health care needs of
the mi:sses, even today as many as four-fifths of the
population of the country does not have access even
to most elementary health care services.
The same “soft state” approach governed the
formation of alternatives in medical education. The
need to radically reorientate medical education to
suit the conditions
in India was
recognized way back in the early fifties. Since then,
numerous committees, seminars, conferences and
workshops have dutifully
reiterated the need for
such reorientation.
Yet the system of medical
education remains heavily oriented to the conditions
of the highly industrialized countries, with emphasis
on highly sophisticated, curative practices, along
with all their paraphernalia
of mystification,
and total submission to the
dictates of the drug industry.
A political system that actively encourages a change
process which promotes involvement of all segments
of the population in the development of health
services and in their implementation as a part of
their involvement in the larger sphere of services in
the .social i..nd economic fields, is an essentiai
prerequisite for setting up any meaningful alternative health care system for India. Such democratization is not possible in a stratified society where a
small privileged class controls the social and
economic life of vast masses of the people. A
campaign for active promotion of a people-oriented
alternative health care system thus, in fact, becomes
a potent tool for pressing for change in the political
Active community
UNICEF photo by J. Ling
in building for a heaM
As a result of democratization, medical technology
is subordinated to the interests of the community: the
health services system is demystified, deprofessionalized, debureaucratized and decommercialized to
provide better services to the masses. Such a
of the medical technology to the
community needs should lead to basic changes in
the entire “culture” of the health services system:
changes in the value orientation of the personnel
within the services, changes in the institutions for
education and training of health workers and
changes in the approach to research.
Under such changed circumstances, the challenge in
the field of research will be to develop a wholistic
research perspective which covers the entire health
system. Attempts thus far have been to see, in an
arbitrary manner, often without using any research
methodology whatsoever, only fragments of the
whole, in the form of mass campaigns, basic health
workers, multipurpose k*::orkers, difficult areas and
peasant physicians and practice of the indigenous
systems of medicine. Indeed, many of these
fragments will acquire an entirely different relevance
when they are seen from a wholistic perspective.
project : villagws making cement slabs for latrines in Aftianistan.
Four major categories of variables which are
obviously relevant for acquiring such a wholistic
perspective for rural health services are:
1. Variables related to the different dimensions of
the various community health problems, including the ecological, cultural, social and economic
factors which determine these dimensions of the
problems. For exemple, in the field of tuberculosis, epidemiological surveys provide vital information concerning the size, extent, distribution
and time trends of the disease; assessment of
tuberculosis as a problem of physical suffering
and economic suffering and the response of the
victims to such suffering provide information
which is of critical importance for formulation of
an alternative. Similarly, analysis of ecological
factors, e.g., the resistance of the host, mediating
factors in the environment and the virulence of
the agent, provide critical insights for developing
a mote rational strategy for dealing with the
2. Variables related to identification
of an appropriate medical technology. It is essential that
technology for dealing with a health problem is
not considered in isolation from other factors
which are relevant to the provision of health care
to a community. A technology for a given health
problem should be a part of a package of
technologies for dealing with the health problems
of the community as a whole; and that package
has to be shaped to fit in not only with the
agency for delivering the package but also with
the acceptance of the package by the community,
its applicability
in terms of the resource
constraints and its epidemiological
There is thus an intimate and often very intricate
not only amongst various alternative technologies
for a group of health
problems, but also between such a package of
technology with the epidemiological character of
the health problems, available resources, agency
for delivery, and above all, with the community
or the consumer.
3. Variables related to the agency for the delivery of
health care. Here, again, the community is the
pivot. Social and cultural data are basic to
of a network of personnel which
will deliver the’ health services needed by the
community. Such supportive factors as supplies,
transport, referral system and the entire supervisory echelon are also included under this
category of variables; and,
4. Variables related to education and training of
health workers of different categories, research,
planning and evaluation.
Consideration of the numerous variables under
the above four, and other, categories requires
adoption of a wholistic approach to forrmlation
of alternatives.
A health care system is an
organized complexity in which its several components are in complex interaction with one another.
As it is not always possible to take into account all
the variables of such a system, it becomes necessary
to identify at least the key variables within the
system which are of decisive relevance. Data on the
key variables are then used to formulate a number
of alternative ways of providing health care.
Making of forecasts (with or without the aid of
models) concerning the relative
effectiveness of the formulated alternatives helps in
identifying one or more of them which is (or are)
likely to be most effective. As the data that have
been used for making such forecasts are not always
very precise or even very reliable, and as the
forecasts themselves have often to be made on the
basis of some hunches rather then on well-established quantitative behaviour of the key variables, it is
particularly important to subject the data and the
postulates or hunches which led to the choices of
the solution to practical test under live conditions.
The choices should be test run, which either
confirms the forecasts or, if not confirmed, provides
a framework for making aiternative choices. Once
the choice is well tested, it is recommended for
implementation on a community-wide scale.
Techniques such as operational research, systems
analysis and linear programming are very relevant
for studying such complex systems. By the use of
such techniques, data concerning the different
components of a system, which are derived from
concepts and methods of a variety of disciplines, are
processed and synthesized with a view to formulating an alternative system which is more effective;
these techniques are used in an attempt to
“optimize” the use of the available resources. These
techniques also provide a framecvork for identifying
the direction of research that is to be carried out in
the laboratories, in the hospital wards and in the
community at large in order to make the system as a
whole more and more effective. It is particularly
noteworthy that, in following such approaches to
research, priorities for research in specialized areas
are determined by the overall requirements of the
health care system. Research in health care systems
thus does not preclude research activities in highly
sophisticated fields. It only ensures that, as long as
the central focus is the community, the distribution
of resources for research shouJd be determined by
the requirements of community health research,
rather than by the personal preferences or biases of
individual research workers.
has been
democratization of the political system, through a
change in the “culture”
of the health care system,
will stimulate research work which is specifically
directed towards making more effective use of the
resources for providing health care services to the
people, particularly
to those who were earlier
neglected. This, however, does not imply that action
will have to wait till findings from complex,
time-consuming researches are made available. In
fact, while such researches go on, the same political
forces will actively press decision makers and
research workers to come out with specific
alternative programmes for immediate action that
can be formulated by making judicious use of all
available data and, where required, supplement the
data with intelligent hunches. A built-in feedback
system and ongoing research on the alternatives will
ensure that the suggested alternative for immediate
action is constantly monitored and its performance
An obvious framework for suggesting an alternative
to the existing approach of “selling”
technology to the people will be to start with the
people. This will ensure that technology is harnessed
to the requirements of the people, as seen by the
people themselves, i.e., technology is subordinated to the people. This alternative enjoins that
technology should be taken with the people, rather
than people taken with technology, by “educating”
Based on their way of life, i.e., on their culture,
people in different communities have evolved their
own way of dealing with their health problems. This
concept forms the starting point, indeed, the very
foundation of the suggested alternative for immediate action. People, on their own, seek out
measures to deal with their health problems.
Meeting the felt needs of the people, which also
happen to be epidemiologically
assessed needs,
receives the top priority in such a framework for an
alternative. People should not be “educated” to
discard the measures that they have been adopting
unless a convincing case is made to show that, taking
into account their own perspective of the problems
and under the existing conditions
of resource
constraints, it is possible to have an alternative
technology which will yield significantly
benefits to people in terms of alleviation of the
suffering than is caused by a health problem.
As is the way of life, health behaviour of a
community is a dynamic phenomenon; it changes
with changes in the epidemiology of the health
problems, available knowledge relating to such
problems, availability of resources and other such
considerations. Therefore, to be based on such a
dynamic phenomenon, the alternative for immediate
action is required to be correspondingly accommodative.
More detailed suggestions for immediate action
concerning the major components of the alternative
framework which is based on the above concept are
as follows:
Medical Care
Community members may be encouraged to make
maximum use of self-care procedures through
continued use of various home remedial measures.
The services of locally available practitioners of
various systems of medicine should be used as a
supplement. Another supplementary
resource can be created by providing training to
primary health workers, who
are specifically drawn from among the weaker
sections, who can make available home remedies and
remedies from the indigenous and Western systems
of medicine for meeting the medical care needs.
Services of full-time health auxiliaries may be used
only to tackle more complicated cases and those
which need more specialized care.
Maternal and Child Health Services
Here also, the key workers are those who have, thus
far, been providing services to the community: the
family members assisting in childbirth and child
rearing and the traditional
birth attendants. The
birth attendant or any other community-selected
member can be trained as a primary health worker
to work with the members of the community to
improve the work that is already being carried out
there and to provide assistance when called for.
They, in turn, are backstopped by the full-time
auxiliary health workers and by the primary health
managerial physician and other referral services.
Findings concerning oral rehydration of children
with severe diarrhoea provides a very valuable
technological device which can be used by the
mothers themselves when their children suffer from
diarrhoea, with birth attendants, primary health
workers and other full-time employees providing
support to these mothers. Primary health workers,
similarly, can be valuable agents for providing
is trained to monitor weight gain of her child. The
primary health worker, again, can organize the
community resources to provide some form of a
creche to the children of the mothers who have to
go out to work in the field.
Control of Communicable
Even with existing strategies which were mostly
developed to deal with many communicable diseases
as “vertical” programmes, PHC workers and other
personnel can take over many of
the duties that are at present being carried out by
specialized unipurpose health workers. Surveillance
of malaria and smallpox, treatment of cases of
leprosy, filaria and trachoma, spraying of houses
with insecticides and water management, including
vector control, are some of the duties that can be
taken over by the community. Demystification of
diagnosis and treatment of tuberculosis patients has
made it possible to bring about a shift in the work
from trained professionals to workers at the
level and at the level of auxiliary
workers at the health centre. Similar studies
concerning other communicable diseases can also
lead to demystification
and simplification
technologies so that they could be made use of by
the community itself or by auxiliaries with limited
Regulation Programme
The PHC approach, particularly
when it is a
component or a rural development programme, is
likely to have a profound influence on the fertility
regulation measures. Education of women, opening
up of employment opportunities for them, their
participation in community activities, greater social
justice and fall in the maternal and child mortality
and morbidity in particular, and of the mortality
and morbidity
rate of the total population
general, are likely to materially change the level of
for a small family norm in the
community. Rise in the age at marriage of men and
women is expected to have a direct demographic
impact. Even within the limited framework of
primary health care, methods such as the use of
condoms and other “conventional”
coitus interruptus, the rhythm method and the
pill may acquire much greater
significance with the people.
Community health workers will be most appropriate
persons to support such community activities by
providing the needed contraceptives. They also can
be a vital link for the community to make use of
other methods such as male and female sterilization,
induced abortion and IUD insertion at the health
Specificaliy, among other considerations,
involve adequate support at the levels of:
this will
- Supervision: providing technical support, guidance and encouragement to workers at health
centres and at the village level;
- Logistics: in the form of drugs, equipment, other
supplies, transport, etc.; linking primary health
care with regionalized health care services at the
national level: by ensuring to and fro exchange of
patients, personnel and facilities and developing a
to and fro communication system;
- Community orientation of education and training
of health workers: this is a most vital element for
promotion of primary health care. It is essential
for suitable socialization of community health
workers. Concepts of organization and management of PHC are so articulated that they form the
content of curricula for providing education and
training of all categories of health workers, from
the most sophisticated to the most elementary
health worker;
- Research and evaluation: primary health care is a
dynamic concept which needs constant monitoring and research input to improve its cost-effectiveness. The premises, the problems, require an
entirely different approach to planning. Correspondingly, constant research efforts are required
to keep on readjusting and reinforcing
programme to keep it in tune with changing
- Planning: principles of PHC require an entirely
different approach to planning; it is planning for
health and not for health services, with the
understanding that such planning for health is a
component of the overall socioeconomic planning. Secondly, even within the limited framework
of planning for primary health care, emphasis on
starting from the people requires an entirely
different approach to planning, i.e., planning
from below.
Sanitation Programme
Thus far, progress in this field has been very sluggish
due to heavy cost and lack of community
participation. Community involvement in environmental sanitation programmes through efforts of
health workers and interdisciplinary
research efforts to develop technologies that are
appropriate to the specific conditions in different
rural communities will contribute significantly
increasing the cost-effectiveness of the programme.
Integration of Primary
National Health Services
It is essential that the principles underlying primary
health care are fully accepted and assimilated at all
levels of the health service organization,
particularly at the highest level of decision making.
Formation of the alternative is essentially a political
question. Health services and other social services
and economic considerations that influence the
health status of a community
are considerably
influenced by the nature of the political system of a
In political systems which perpetuate
domination by an oligarchy, alternative systems are
formulated either to find more effective approaches
to serve the ruling oligarchy or to provide an aura of
legitimacy to an obviously unjust social system by
arousing false hopes among the masses. A sociai
structure manifesting acute polarization between the
haves and the have-nots is inimical
to the
development of an alternative health care system for
meeting the needs of the entire population.
Democratization of the political system is the key to
the formation of an alternative.
In the case of India, where the process of
democratization has not yet reached the underprivileged and the underserved to any significant extent,
the health service system continues to nurture the
colonial tradition of having a curative, urban and a
privileged class orientation. The ruling classes have
actively promoted those alternatives which served
their interests. Expansion of Western-oriented
medical education and establishment
of more
for curative services, often of very
sophisticated nature, in urban areas, are instances of
such actions. Search for an alternative health service
system to cover the entire population has been
half-hearted. Even the few promising lines of action
that were developed under such unfavourable
were not implemented
enough. A political system that actively encourages
of the entire population
in the
development of the health services and in their
is an essential prerequisite for
setting up any meaningful alternative health care
system for India. Democratization of the political
system will subordinate medical technology to the
interests of the community: it will be demystified,
and decommercialized. it will bring about a change in the
entire “culture” of the health service system.
The challenge in the field of research to form an
alternative health care system will be to develop a
wholistic research perspective for the health system
in its entirety. Four major categories of variables
which are obviously relevant for acquiring such a
wholistic perspective are:
variables related to the different
sions of the various community
variables related to identification
appropriate medical technology;
variables related to the agency for the
delivery of health care; and,
(iv) variables related to education and training
of health workers, research, planning and
While such researches go on, it is possible to single
out specific alternative programmes for immediate
action by making judicious use of all available data
and supplementing them with intelligent hunches.
These specific suggestions for immediate action
cover the fields of medical care, maternal and child
health services, control or eradication of communicable diseases, programmes for fertility regulation,
environmental sanitation and integration of primary
health care with the national health services.
1. Newell,
K.W. led.), Health by
Health Organization, Geneva, 1975.
2. Indian Council of Medical Research and Indian Council of
Health Care Delivery System: Background
Papers, Hyderabad, 1976.
3. Government
of India,
Committee, Managerof Publication,
and Development
Report Volume IV,
New Delhi, 1946.
4. Indian National Congress, National Planning Committee,
National Health Report. Allahabad, 1948.
5. Government
of India, Minstry of Health and Family
Planning, Committee on Utilization of PHC Beds in India,
Report, New Delhi, 1947.
6. Government of India, Ministry of Health, Committee on
Integration of Health Services, Report, New Delhi, 1963.
7. Government
of India, Ministry of Health and Family
Planning, Committee on Multipurpose Workers, Report,
New Delhi, 1973.
6. Government
of India, Ministry of Health and Family
Planning, Outline of Master Plan for the Provision of
Health, Medical and Family Planning Services in Rural
Areas, New Delhi, 1970.
9. Government
of India, Ministry of Health and Family
Planning, National
Health Scheme for Rural Areas,
(Revised), New Delhi, 1972.
Maria das Merces G. Somarriba
The concept of the distinction
between the
and the effectiveness
of a given
organization seems quite appropriate to the analysis
of the performance of health institutions. This is so
because, as argued in the sociological literature on
formal organizations, often the over-concern with
efficiency (production of units of output) limits the
scope of activities of an organization, while its
effectiveness (degree to which it realizes its goals)
might require a large variety of activities and a large
amount of time.1 And, more than in any other
sector, there is a clear distinction in the health field
between the quantitative production of services and
the achievement
of improvements
in health
conditions. Such improvesnents clearly are a relevant
aspect of any health institution’s goals, and they are,
in the final analysis, the definition
of the
level of effectiveness. By showing a
concern for the distinction
between the two
concepts, we do not imply that they are
independent when applied to the health field. Here
too, as in any other sector, effectiveness presupposes
Why, then, is that distinction
ever-increasing investments
pensive medical technology.2
in complex
and ex-
The lack of correlation between investments in
medical technology and health improvements is even
higher among the people who have no protection
against the harshness of the environment. In this
context, the distinction
between efficiency and
effectiveness becomes crucial. In other words, the
current medical approach, which lays stress on the
production of health services, tends to be ineffective
amongst the poor.
The distinction between efficiency and effectiveness
in the health field underlies the proposal for
community participation in health, which has been
put forward recently.
In the first place, health status is dependent on
wider socioenvironmental
factors. To this extent,
the effectiveness of most medical interventions will
be heavily dependent on factors which lie in fields
beyond medical control.
Justifications for the development of community
health programmes are found, first of all, in the
extremely uneven distribution
of health resources
prevailing in most capitalist countries. The utilization of auxiliary personnel and simplification in the
use, of technology
in medical practice have
the extension of health services
through these programmes. To this extent, the
strategy of community health deviates from the
dominant concern of technological medicine.
Secondly, for complex reasons linked to social class
interests in past and present times, current medical
practice has been directid mainly at the extension
of the concerns of clinical medicine. Meanwhile, the
notion that most diseases are caused by socioenvironmental factors has been neglected. As a result,
there is a contrast between the current efforts which
stress new technical developments in medicine, and
the decreasing returns to health brought about by
Another reason for the development of community
health programmes is the recognition that the
dominant approach to health problems amongst the
poor is ineffective. Many health experiments in poor
areas have pointed out that, if the patient leaves the
health institution (hospital, health centre, etc.) and
comes back to the same unhealthy environment, he
or she will probably soon need health care again. It
has been widely demonstrated that the simple
provision of health care at the level of health units
located outside the poor communities is not a useful
way of tackling their health problems. As a result,
the objective of medical practice put forward by
community health programmes is not care to the
individual as such, but to whole social groups, the
poor communities. This kind of health programme
lays stress on the participation
of the whole
community in the solution of its health problems. It
is recognized that, unless the community involves
itself in the health programme, all efforts to effect
and in human
changes in the environment
behaviour, to produce a healthier way of life, will be
lost. Community participation is seen, therefore, as
an important determinant of the effecr%eness of the
health programmes.
At first glance, it appears that community health
programmes question the main features of the
dominant view of health care: they propose the
reunification of the traditionally divided activities of
public health (preventive measures) and personal
medical care (curative measures); they supposedly
break with the current medical approach since they
bring back the lost idea thar most diseases are
caused by environmental factors; finally it seems
that these programmes can contribute to reduce
social inequalities in the health field, since they
provide the extension of heahh care to social sectors
formerly excluded from the programmes.
But, in so far as the model of community health has
been designed exactly for the poor, a basic question
arises: to what extent can this model be congruent
with the principle of socioecological causation of
diseases? The recognition of the role played by
socioeconomic factors in the genesis of diseases
points directly to the necessity for social retoirns.
The fact that the model calls for community
participation at first sight, seems to be linked to
such a necessity. To this extent, is the proposal olt
community health a modern version of the old and
highly politicized concept of “social medicine”? As
stated by Rosen, 3 this concept was developed in
connection with the Jacobinic ideals of social
when medicine was perceived as an
instrument of social reorganization.
A brief analysis of a community health programme
which has been carried out in a poor region of
Brazil, can throw some light on the issue. Such an
analysis will be made in the remaining sections.
The Health Programme Origins
In 1973, a basic agreement was signed by the
Brazilian Ministry of Health and USAID to make
available a loan to aid the establishment of health
care delivery systems in the poorest areas of
northeastern Brazil. In April 1975, a new health
programme was started in Norte de Minas, utilizing
the USAID loan and special donations provided by
the Ministry of Health.
Strong emphasis was placed on the extension of the
coverage of the health services, mainly to the rural
areas. The higher authorities in the public health
sector (Ministry of Health and State Secretariat of
Health), increasingly saw the Norte de Minas
programme as a pilot experiment for the establishment of an alternative health care delivery system in
the poor areas of the country.4 The programme was
guided by the following basic principles:
First, there is the programme’s quantitative aim to
extend service coverage to at least 70% of the
regional population. This is the aim that has been
mainly emphasized by the international, national
and state institutions that are financing the health
Secondly, there is the qualitative aim. These services
would be delivered within the scope of an integral
service in which the preventive, curative and
activities are carried out concomitantly, as parts of one unified effort to change the
population’s state of health.
With the exception of the use of the experiment as a
guideline for other regions in the country, the other
basic principles could be seen as the means to
achieve the model’s quantitative
and qualitative
objectives. Among these means, one can distinguish,
the basic set of politico-administrative
activities which consist of the coordination
institutions, the obtaining of finance, the administrative decentralization and the establishmen! of a
hierarchy of the health services. The centre of these
activities is a set of institutions directly committed to
health activities. The health system’s clientele are
not directly involved in these activities.
The second set of means has a sociopolitical
dimension which directly involves the population
who benefit from th& services. These activities
include the utilization of informal health manpower,
the employment of auxiliary personnel and the
participation of the local communities in the health
system. The basic assumption here is that the
region’s health clientele will not only be a simple
input of the system but will also become an actively
integral part of it.
Now, let us briefly discuss the understanding of the
programme’s fundamental policy definitions among
the people directly involved in the health programme implementation at the regional level.
The Regional Heaith Centre (RHW
Stress on Community Participation
At the level of the RHC, the health programme’s
original priorities underwent significant changes.
This does not mean that a complete redefinition of
principles and objectives had taken place. The RHC
leadership group was conscious of the fact that the
programme’s continuity
was dependent on the
achievement of the basic goal for which the
institutions providing financial support were looking. But there is strong evidence that community
participation came to be regarded as a fundamental
proposal which constituted an end in itself, even
more important than immediate coverage extension.
But what concept of community participation did
the members of the RHC technical team have in
This question is very relevant because of the various
views of the concept, both in the sociological
literature, and in the several social contexts where
there is some experience of popular involvement in
concrete programmes.
In fact, the idea of community participation can, at
one extreme, have a very limited scope with an
emphasis on its immediate utility. For instance, it
can be no more than the concern for getting the best
out of human and material resources in cases where
they are misued and dispersed, in order to increase
the available resources for the provision of services.
At the other end of the spectrum, the concept of
community participation can imply a strong sense of
social transformation, meaning even the redefinition
of the power structure in a given social unit.6
The first concept of community participation can be
viewed as maintaining
close links with the
traditional approach to community development,
which lays stress on such issues as group solidarity,
sharing values, consensual commitments and cooperaWe activities among the members of a
community. The basic characteristic of this model is
the weight it gives to the idea of common interests
as a determinant of the social dynamics. According
to this approach, the lack of mobilization of the
community and of organization, supposedly found
in most social units, are the main difficulties to
In terms of the proposal of decentralization of health
policy, formally stated by Minas Geraishealth authorities,
this state is divided into 16 Health Regions. A regional
health centre constitutes the administrative body in
charge of the public health activities in each region. The
Norte de Minas Health Region covers around one million
Stressing the redefinition of the socioeconomic and
political. conditions inside the community, and also
of the relationship between the community and the
larger society, the second concept of community
participation seems to be closer to the sociological
approach concerned with “conflict theory”. This
theoretical approach emphasizes the role played by
socially opposed interests in the determination of
social development. This second approach questions
the real possibilities of consensual commitments and
it does not deny the
relevance of popular organization and cooperation
for the solution of common problems, nevertheless
it emphasizes the fact that, very often, people who
are willing to engage in some kind of collective
action, to realize a common goal, might be involved
in a conflict situation, because people and social
groups have different socioeconomic and political
positions in most social units.6 Given these
differences in the sociai structure, too much
emphasis on common interests can be unrealistic. It
leads to the underestimation of actual and potential
which a mobilized
and organized
community has to face when it seeks objectives
which are not so common and goals which are not
so collective. This second approach would suggest
that any community programme should start by
identifying the main conflicts of interest inside the
In the Brazilian (and Latin American) context, the
search for such an awareness regarding socially
conflicting interests has been described by the idea
of conscientiza&So (consciousness raising). This
concept, which owes much to Paulo Freire’s
apprc.?ch to the educational process,7 implies that
the solution to the problems of the exploited people
must ultimately come from the people themselves:
those community sectors which have disadvantigeous socioeconomic and political conditions must
become aware of these disadvantages in order to t$e
able to find solutions to their problems. After the
people have become aware of the problems and have
opted for change, they need to be mobilized to
bring about changes in the socioeconomic structure
and in the political structure which legitimates it.
It was verified that the RHC’s top leadership group
had developed a conflict view of community
from their approach to the determinants of health problems, which underlies the
moael of community
health.6 Thus, the group
believed that, since the main causes of ill-health in
the region are related to the existing social
inequalities, community participation should focus
attention on the differences of interest found in the
communities. The first step of this strategy should
take place through [email protected]:
the programme’s “clients” - the poor strata - were to
become aware of the main conflicts of interest
which affect their health chances within the
A health
by Y. Pouhquen
and advice,
Thus, when the RHC started
to implement
the (abstract) model proposed from
higher up, there was a diversion from the original
proposal and all the emphasis was placed on a
strategy of community
which clearly
has a political meaning. The team did not limit the
proposed community
action to consensual issues but
a “maximal”
of community
in health
programmes was perceived as a tool for pressing for
changes in the economic
and political
Instead oi tr’Y, the production
of health services
become the
uy.~~ of the proposed community
health progrzmmes: the highest priority
was placed
on using hPdltt# as a way to motivate people to press
for improving
their overall living conditions.
As a
result, the model of community
health which arises
contains (potentially)
the questioning
of the social
inequalities amongst classes, sectors and groups.
The following
is a brief attempt
viability of the health programme.
to evaluate
The extension of health services
health programmes is primarily
hrough community
dependent on the
to mothers
and children
in Peru by a trusted
of their
and reallocation
of the available health
the provision
of additional
financial and human resources in the health sector.
In terms of human resources, additional
is generally provided through the wide
use of auxiliary cadres. This has also been the case in
the Norte de Minas Health Programme.
As for financial
resources, the division
of labour
between the contractual
health insurance sector and
the public health sector, found in Brazil, is a key
This division
of labour
separates those
medical actions which are economicaily
and mainly hospital-based
medical c&i
under the control
of the health insurance sector)
from those which are not profitable
(curative and
actions oriented
groups of people controlled
by the public health
can only
As such,
in terms of a political
option towards
and strengthening
of private
the preservation
interests in the health sector.
The implication
of this political option for a health
programme which tries to break with the prevalent
between preventive and curative care is
that financial resources are likely to be scarce. As a
matter of fact, the overall amount of resources spent
on health in the region is very low indeed. This is so
because the expenditures of the sociai insurance
sector in the region are low, particularly when they
are compared to allocations in other regions. The
situation could not be different sine% the funds of
the social insurance programmes are usually spent
on the more complex curative services provided by
hospitals (generally under the control of the private
sector), and hospital facilities are scarce in the
region. The fact that 80% of the social insurance
programme resources allocated to the region are
spent in the r.,ain city - where hospital facilities are
concentrated, and the private sector’s interests are
stronger - is the direct result of such a definition of
priorities by those who control the health insurance
sector. The result is that effective coverage achieved
by the social insurance institutions in the region is
very low, and the potential
clients of these
institutions must depend on the scarce resources of
the public health sector for primary health care.
Also as a result of the dominant commitment to the
private health sector interests, great difficulties have
arisen in the many attempts at coordination
between the RHC and the health insurance
programmes operating in the region. These latter
institutions continue to spend their comparatively
low amount of resources on the kind of medical care
which is used by a small proportion
of the
Unless significant
changes come about in the
country which will redefine the priorities in health,
as well as in other fields, there is little chance for the
highly desirable reallocation of the resources in
favour of the critical needs of the majority. The
prevailing pattern of resource allocation in the
health field is closely connected to wider political
options which have been encouraging concentration
of wealth and power in Brazilian society.
The productivity
of the Norte de Minas Health
Programme could be increased to some extent if the
scarce resources of the public health sector in the
region were spent in a more coordinated fashion.
However, the very administrative structure of the
Ministry of Health - organized around a number of
organs which carry out their activities in a
centralized and vertical way - seems to constitute
the main constraint. At the same time, the poor
performance of the Ministry
Health seems closely linked to its growing weakness
vis-&is the health insurance system.9
The extension of hedlth services into the Norte de
Minas is not enough to change the prevailing disease
pattern, related as it is to the socioeconomic
conditions existing in the region. To this extent, the
concern shown by the RHC’s leadership group with
the transformation
of the living conditions of the
poorer sections of the communities
surely is
As the strategy of community
chosen by the group potentially
involves questioning the basis of poverty and social
inequalities, the health programme can develop into
a tool for pressing for changes in the existing
economic and political system. However, in view of
the nature of the Brazilian State and the regional
there are very real
obstacles to the RHC’s attempt to achieve a greater
range or depth of community participation. Some
considerations of these issues are in order.
The prevailing national political strategy favouring
rapid economic growth has led to a pattern of
development highly dependent on the concentration
of wealth and incomes. At the same time, economic
efficiency has been achieved through the creation of
severe constraints to political participation, mainly
in relation to the popular classes. These broad trends
at the national level are clearly reflected in the
regional socioeconomic
and political
where landownership remains highly concentrated,
where the income levels of the majority remain
extremely low, and where a new, very poor rural
proletariat without
rights is the result of the
extension of commercial activities into the subsistence sector. The suppression of former movements towards unionization
and agrarian reform,
and the largely restricted political climate created
after 1864, have helped to maintain the rural
masses’ low level of political consciousness about
their situation of dependency and exploitation.
Thus, on the one hand, thorough structural reforms
will be needed to break the cycle of poverty-disease
found in the region. On the other hand, the
prevailing political climate obstructs any serious
to question the basis of the social
disadvantages faced by the majority, as a threat to
the continuity
of the Health Programme. In the
present context, we can hardly speak of the
existence in Brazil of a national commitment to
support/encourage, or even accept, active political
involvement by the people. Therefore, concerning
this first factor that influences the degree of
community participation, the existing situation is
highly unfavourable.
Concerning the institutional environment faced by
the RHC, the concern with a greater range or depth
of community participation separates the RHC from
almost all other institutions and/or institutional
levels involved in the regional health programme.
Indeed, the quantitative
produc#ion of health
services is by far the dominant concern at the higher
institutional level. This dominant over-concern with
efficiency constrains the RHC team commitment to
community actions, which require more time, effort
and skill on the part of the health personnel. One
example of conflict between the RHC and the State
Secretariat of Health on the issue of the evaluation
of the programme’s productivity
can illustrate this
A model for collecting information was designed by
the central level to control the health units’
The RHC, however, expressed strong
criticisms and disagreement with the great concern
of the Health Secretariat for quantitative
“‘From the discussion on the Information Model,
criticisms arose on its bureaucratic character. This
model places emphasis on individual care in so far
as it is concerned with quantitative information,
such as the number of primary care contacts per
person. We think that the work with collectivities
needs to be emphasized. We decided, therefore, to
prepare a bulletin containing general orientation
on this matter, which has been delivered to the
health auxiliaries. -10
That bulletin stresses the low efficacy of individual
health care to bring about changes in the
population’s health status and emphasizes the need
for collective actions:
“We cannot limit ourselves to these actions with
individuals or families. The most important task is
to prevent diseases and this has to be carried out
through collective actions involving many people
at the same time... This is so because, for carrying
out really effective action, M need to know, first
of all, the real problems which influence people’s
health. These problems can be immediate ones as
when there are cases of measles, typhus, etc., and,
in this situation, quick action has to be taken in
order to get people vaccinated. Or the problems
may have a rather permanent character, as when
they are linked to housing, nutrition, etc. In this
case, there is the need for more long-term
efforts. “11
It seems that the conflict between the RHC and the
central level concerning the evaluation of the health
programme’s performance is closely related to the
frequent contradiction
existing between the effectiveness and the efficiency attained by ii given
organization. In Norte de Minas, this contradiction
between efficiency and effectiveness seems to arise
because, side by side with the search for the
extension of coverage - the model’s quantitative
aim, achieved through the increasing production of
health services - there is the RHC’s concern with
the model’s qualitative
aim, i.e., the effective
improvement of the population’s health status. As
\IIR have seen, the RHC’s leadership group stresses
the social causes of health problems, as well as the
need for collective actions of a political nature,
which involve the complex idea of [email protected]‘o,
for tackling the population’s basic health problems.
That is why, in the search for effectiveness, the
RHC’s top leadership group appears so committed
to what could be called a “maximal” strategy of
community participation.
At the same time, most institutions
levels acting in the region place
absolute emphasis on the vertical decision-making
process, through their highly bureaucratized and
centralized administrative structure. Consequently,
the dominant ideas on the role of the clientele are
highly inconsistent with the RHC’s approach to
There is far too little
decentralization of government administrative decisions and procedures in the regional health sector
for it to be consistent with the principle of
community participation.
As for a third determinant
of the degree of
i.e;, the degree of
organization and communai solidarity at the local
level, the existing constraints also cannot be
underestimated. Firstly, the scattering of a great
part of the regional population over a wide area
leads to social isolation and acts against the
development of links of horizontal solidarity among
the clientele of the various auxiliary health units.
Thus in soma areas, even the lower degree of
(for example, through
self-help projects in which the whole community is
supposed to contribute labour and/or material) can
hardly be implemented. To this double isolation physical and social - we must add the lack of
provision of services and facilities by the state to the
bulk of the regional population. Finally, there is the
fact that the large landowners and traders have
control over the basic means of production, namely
land and the locally available credit. These factors
together create a situation in which the poorer
sections j of the population
tend to be highly
dependent on the locally powerful.
Such a
dependency diminishes the possibilities of raising
the level of collective consciousness amongst the
poorer sections of the local communities.
constitutes, therefore, a limitation to the RHC’s
proposals in this connection.
From this summary of the main limitations to the
health model, one can conclude that the proposals
held by the RHC’s leadership group, at the
beginning of its activities, were both “idealistic” and
“realistic”. They seem “idealistic” in so far as they
express a deep commitment to the betterment-of
the poor living conditions of the majority in such a
discouraging social environment. But this commitment also has a strongly “realistic” sense, based as it
is on the group’s sensitivity to the socioenvironmental approach to health problems. It seems, therefore,
that the regional health programme has faced, from
its very beginning, the dilemma contained in the
community health programmes which are based on
the conflict model of community.
Having been
originally conceived as a pilot experiment for a
moderate reform of the country’s health system, it
soon came to be viewed as a way of raising the
consciousness of the poor strata about the
deeply-rooted social causes of their health problems.
Thus, the dispute around the meaning of comwhich necessarily characmunity
terizes the implementation
of community health
programmes in capitalist societies, emerged in Norte
de Minas even before the local communities became
involved in the health programme. This has been so
because, first of all, the basic ambiguity posed by
the fact that the call for participation in health has
been directed to the poorest social strata was
promptly and clearly perceived by the RHC’s
leadership group and secondly, because this group
to sewing the
interests of the poorer sections of the population.
How this dilemma is going to be dealt with by the
RHC’s team is an open question. But there are
gounds for expecting that, as the implementation
of the programme proceeds, the team will conceive
of concrete strategies which continue to keep the
precarious balance between the many contradictions
involved. This has been the case up to now. After
all, when a group is really committed to the need for
social transformation, its members are likely to find
ways to face the contradictory
features of social
reality and to use them to bring about changes, even
if on a small scale. There is little doubt that the
RHC leadership group does indeed present such a
Thus, the Norte de Minas Health
Programma constitutes, without
any doubt, an
in the health field. It
questions the basic features found in various degrees
in the health sector of most capitalist societies. And,
as these features - division between the activities of
public health and personal medical care, prevalence
of a curative approach, and wide social inequalities
in the distribution
of health care - are found in
Brazilian society to a high level, the Norte de Minas
Programma can be taken as a pilot experiment that
puts into question the entire organization
of the
health sector. Given the critical problems
in this sector, that health programme
probably influence health policies, once more liberal
be established
in the
1. Amitai Etzione, Modem Organizations,
Englewood Cliffs, N.J., 1964.
2. John Powles, “On the Limitations of Modern Medicine”,
Science, Medicine and Man, I, 1973.
3. George Rosen, A History
Monographs on Medical History,
Public Health,
1, MD Publications,
4. M.M.G.
Health and CIas
the Health kogramme
of Norte de Minas,
Brazi/, D. Phil Thesis presented to the University of
Sussex, England, 1978.
5. Economic Commission for Latin America, “Popular
in Development”,
VIII (II). 1973.
6. Emanuel de Kadt, c?rho/ic Radicals in Brazil,
University Press, London - New York, 1970.
7. Paul0 Freire, Edu+scao coma Pratica da fiberdade,
Terra, Rio de Janeiro, 1967.
8. M.M.G. Somarriba,opcit,
Paz e
ch. VII.
9. /bid., ch. I II.
10. Ibid., p. 203.
11. Ibid,
pp. 203204.
Budd L. Hall
In 1975, over three million people in rural Tanzania
took part, though discussion and action groups, in a
campaign on food production and nutrition called
Chakula ni Uhai, (Food is Life). This campaign,
made use of weekly radio broadcasts, printed
materials and over 100,000 trained study group
leaders. Early campaigns, on a small scale, were
conducted on themes such as the popularization of
the second five-year development plan, the 1970
presidential and parliamentary elections, and the
Qlebration of ten years of independence.’ The idea
of development campaigns has further spread to
Botswana, where a successful campaign on the first
national development plan was completed in 1973.2
The development campaign as it exists in Tanzania
and, to some extent, Botswana, is the manifestation
of several different
streams of activity.
illustration which follows perhaps shows this-diverse
parentage most clearly, regarding the most recently
completed two-million-member
“Man is Health”
The “Man is Health” development campaign fits
within the historical context of many development
efforts and combined aspects of various antecedents
in a national
campaign. It was an outgrowth
of increased
emphasis by the Ministry of Health on preventive or
medicine, an expansion of adult
education experimentation
with radio listening
groups, part of the political party’s (TANU) concern
with increased political consciousness and awareness
of the politics of health, and fell within national
policies for bringing about a socialist rural
transformation (Ujamaa).
The best way to illustrate how this kind of
development campaign works is through a look at
the results of a recently-completed campaign.
The campaign had three objectives:
1. to increase participants’ awareness of, and to
encourage group actions on, measures which
groups and individuals can take to make their
lives healthier;
2. to provide information about the symptoms and
prevention of specific diseases; and
3. for those who had participated in the national
literacy campaign, to encourage the maintenance
of newly-acquired
reading skills by providing
suitable follow-up materials.
Political Education/
Politics is Agriculture”
Health Education
Man is Health
Mass Development
Radio Study Groups
“Time for Rejoicing”
National Emphasis on
Mobilization and Action
“Ujamaa Policies”
Two elements were fundamental to the fulfilment of
these objectives. First, there were preexisting
structures available to implement the plans. Second,
the planning was not rushed and it was thoroughly
Tanzania has built a widespread adult education
network under the administration of the Ministry of
National Education. It is composed of nearly 2,000
national, regional, district and divisional adult
and supervisors. These
personnel are responsible to the thousands of adult
education centres which operate using primary
schools as bases. They are paralleled by a network of
health education officers. Both sets of personnel
were largely responsible for the day-to-day operation of the campaign, from the training of group
leaders to encouragement during the broadcasting.
They were supplemented by the networks of TANU
and the Rural Development Division.
The planning for the campaign began 18 months
before the first radio broadcast went on the air and
was carried out under the guidance of a national
coordinating committee which met as often as
weekly during the more intense planning periods.
The importance of this committee is that, from the
beginning, as many agencies as were necessary to the
success of the campaign were involved. A mass
campaign at a rural level cannot be carried out by
the activities of only one sector or one agency. It
requires the coordinated efforts of all agencies
working in the rural areas. At village level in this
campaign, the adult education personnel worked
with the rural development extension officers, the
local TANU officials and the health education
personnel in organizing groups before the campaign
and in giving the groups support, once the radio
programmes were under way.
Experience from the earlier radio study group
campaigns indicated that a trained study group
leader was essential to successful group activity. One
of the most important reasons for training group
leaders is to convey the message that group leaders
are not teachers. A leader does not tell the group
what to do or how to do it. The group leader is
given training to guide group studies, to understand
that he is only “first among equals”. He must be
trained in tact: to encourage the withdrawn, subdue
the over-dominant
and generally stimulate full
It is equally important to provide
suggestions to leaders on how to move from
discussion to action in the groups.
Logistically, the Tanzanian scheme required 75,000
study group leaders to be trained in 3 l/2 months.
This was done by means of a staged training system
whereby regional teams trained district teams who,
in turn, trained the study group leaders at divisional
level. There were 7 regional seminars for 200
(30 per seminar); 61 district-level
seminars for 1,400 participants (25 per seminar);
and 2,000 divisional seminars for roughly 75,000
study group leaders (37 per seminar). All the
seminars lasted from 2 to 3 days.
An important lesson from this experience at mass
training is that it is possible to ensure that the
central elements of the training message survive the
diffusion process from the first through the last
stages. That is, no vital element need be damaged by
dilution. This is one of the most crucial aspects in
the development of a mass campaign. In the
Tanzanian case, the key elements of the training
message were maintained
by several devices:
handouts (duplicated
the use of prepared flip-over charts summarizing the
most important
points of training; prerecorded
cassettes of simulated radio programmes for roleplaying experience; and copies of the actual
materials to be used in the campaign.
The pa’tiern which was most often followed
groups during the campaign was as follows:
1. assemble during the gathering time - the radio
plays music related to the campaign, political
songs, poems and short announcements;
2. the group members listen to the 20-minute radio
3. the group leader or someone in the group reads
aloud the appropriate section of the text;
4. discussion begins first with the question of the
relevance of the material presented to the actual
circumstances of the group’s members;
5. discussion takes place about various persons’
experience with the disaase, alternative causes of
the disease and possible ways of preventing it;
6. resolutions are made and agreed upon by the
group for specific actions which could be
implemented in the village; and
7. during the ensuing week - before the next
programme - the resolutions are carried out by
the group members and, most likely, others in the
A major difference between this campaign and
previous attempts was the importance placed on
action following discussions. The types of activities
which individual groups undertook varied according
to the reality in various areas. In a survey of 213
groups, it was found that clearing vegetation from
around the homes was carried out by 28% of the
groups, digging, repairing or rebuilding latrines by
20%, destroying and cleaning the areas of stagnant
water by 24% boiling water 12% and cleaning the
area around water supplies 11%. In one district,
(Dodoma) about 200,006 latrines were built during
the campaign period. The result at the end of the
campaign was that nol a sirryie huu~t: wivas.wkhout a
latrine. This happened in an area where colonial
officers had tried to enforce latrine construction
nearly 50 years previously with dismal results and
much rancour. In one division in Iringa, the people
decided that to have a latrine for each home was ncrt
enough. What, for example, could travellers use,
while waiting on the side of the road for buses? The
solution was obviously more latrines. It was agreed,
accordingly, that one latrine would be built at each
major bus stop in the area.
The national average attendance figure for the
campaign was 63%. That is, at any given session
anywhere during the campaign, some 64% of those
enrolled were probably in attendance. This figure
can only be meaningful when compared with the
average attendance of other forms of rural adult
education such as literacy or political education
classes. The Ministry
of National
estimates that actual attendance at any given session
for the nearly 3 million persons enrolled in adult
education classes is about 33%. The literacy project
estimated between 25-40~ attendances per session.
This means that the attendance figures for the
short-term campaign were quite satisfactory.
The following
graph indicates the attendance
pattern week by week, Several points are made.
First it can be seen that, even for the first meeting,
over 20% of those enrolled failed to show up. If the
attendance figures were adjusted to exclude those
who enrolled but never actually attended a session,
the average attendance would rise to almost 83%.
The second point that could be made (from the
graph) is that attendance during the main part of the
campaign was quite steady.
The change from the second through the tenth week
was about 5% points.
Attendance by week
Al I regions corn bi ned
9080 -
60 -
30 20 -
10 -
12 week
WHO photo bY Y. Pouliquen
A woman voluntwrs
to become a healL assistant.
Built into the campaign from the beginning were a
series of measurements and sources of information
designed to aid in an assessmctnt of some aspects of
the campaign. In addition to such routine interest as
total enrolment, national distribution of groups and
attendance rates, the evaluation design provided for
the measurement of the amount of information
gained through this method of study and a
measurement of the change in observable household
health practices as a result of the campaign.
As we start to examine the data from the control
groups, we begin to run into some difficulties.
Perhaps the foremost difficulty in selecting a control
group during a campaign of this type is: how to find
a group of people, in an intensive campaign designed
to mobilize everyone, which has not taken part in
the campaign in some way? In Mafia, for example,
no control groups were chosen because it was said
that, in a national campsign of this sort, all people
had a right to participate in the health education. In
Mitwara, the situation was similarly difficult as
those in the control group were swept into the
excitement of the campaign along with the other,
adult education siudcnts and began to study the
material on their own. The result in this case was
that the “control” group actually scored higher than
the Mtu ni Afya groilps.
Nevertheless, the Mtu ni Afya groups showed a
relative improvement of 47% from the pretest to the
posttest: an increase from 43% to 63%. The control
groups taken together scored a 35% relative gaih,
from 43% to 58%. The Mtu ni Afya groups scored
higher than the control groups, but this difference
was not found to be statistically significant. Only
when the scores from the energetic Mtwara
group are removed are the differences
significant statistically.
If the control group in
Mtwara, the situation was similarly difficult
show an improvement of 21% compared with the
47% of all others. This difference is statistically
significant as well.
Thus, we can say that there is a difference between
the scores of all control groups and all Mtu ni Afya
groups, but that this difference, the better scores of
the Mtu ni Afya groups, must be seen as a tendency
only, not as a significant difference. If, however, one
excludes the group in Mtwara which actually
participated in the campaign, the 47% relative gain
of the Mtu ni Afya groups is fully 26% higher than
the 21% of the control groups. In this case the
difference can be shown statistically not to be due
to chance.
Of particular importance to the campaign was the
measurement of change in health practices. In a
survey done of 8 villages before and after the
campaign, a series of 11 observable health practices
such as the presence of a latrine, the use of the
latrine and absence of broken pots and pools of
stagnant water, combined as a health practices
index. Each household was surveyed and could score
0 and 12, depending on the number of
positive practices observed. Before the campaign,
the mean health practices index for all houses in the
‘8 villages (2,084 houses) was 3.0 or 3 out of 11
observed positive health practices. After the
campaign, the mean index was 4.8, a relative
increase of 60%. In real terms, this means that each
house in the entire sample improved their health
environment by changing nearly 2 negative habits
into positive ones. The largest change in these scores
wme from the digging and construction
of pit
latrines and clearing vegetation from the immediate
vicinity of the house.
The final evaluation
of any health education
campaign must lie in the reduction of the incidence
of disease. Provision of the measurement of the
reduction of disease level was not provided in the
evaluation of this campaign, as the isolation of the
multiple factors associated with good health would
have proved impossible given the nature of the
campaign and the records available. There have been
reports of a large increase in the number of people
attending rural dispensaries in many areas. There is
proof that large numbers of people participated in
the campaign; that people learned from this method
and that literally millions of hours were put into
environmental changes as a result of the campaign.
materials 50~0, distribution
another 6% and radio
production and research the remaining 8%. The
actual production of the radio programme cost less
than 600 dollars additional capital. This is because
production of the radio programmes made use of
the already existing broadcast and radio facilities at
Radio Tanzania and of the services of health
education and adult education broadcasters whose
work was covered in salaries already being paid by
their respective institutions.“”
What this means is
that the campaign was able to reach participants at
an additional cost of roughly 0.10 US dollars per
It seems clear that the Tanzanian large-scale
wnscientization campaign in health education is one
of the most interesting education projects to have
taken place in Africa in recent years. Some of the
most significant
aspects and reasons why the
campaign deserves very close study by those
concerned with development, particularly
development, are:
1. An atmosphere has been created in which people
have been able to take some control of their own
health. It has been all too common for people in
rural areas to see illness as being related to factors
outside their control, or as caused by sociological
difficulties in the community with both present
and past inhabitants. Where the possibility of help
has been recognized, it is seen too much in terms
of modern medicine - the provision of which is
hopelessly inadequate in rural Tanzania. This
campaign has shown that radio and other media
can be used to raise people’s awareness that they
themselves have control over many of the
common health problems and that groups of
people working together can change many of the
least healthy aspects of the village environment.
2. Large numbers of the rural population have been
given access to specific and re!evant information.
The rural population makes up the bulk of all
people living in Tanzania, as well as in most Third
World nations. This campaign has shown itself to
be very effective in reaching a very large portion
of the rural population which has not, in the past,
had access to more formal types of education
costs, shortsightedness
planning or simply different priorities.
The campaign was supported by a grant from the
Swedish International
Development Authority
210,000 US dollars.* Of this capital, training
accounted for roughly 36%, printing of study
3. The methods
The Government of Tanzania annual budgets for related
activities are: 1974/75 Adult Education, Ministry of
National Education US$7,044,000.00.
a realistic
* We assume, of course, that the normal work of those and
other personnel continued,
were incurred.
so that no opportunity
** This compares with about US$3.00 in 19’72 per adult
evening class student for 20 hours tuition per term.
The shortcomings of traditional student-teacher
relationships have been criticized frequently by
people such as Ivan lllich and Paulo Freire. It is
clear that an educational setting for adults who
are to direct their own development cannot rely
on methods whereby one person is seen as an
“expert” or teacher and possesses all knowledge
and others simply recipients of knowledge. The
emphasis in this approach is on complete and
equal participation by the group members: they
actively explore the relevance of the information
to the reality of their own lives. This joint
creates lively understanding of a
personal situation for each one involved and
becomes a strong
element for
improving community life.
4. Cost per participant is low.
The campaign, by making use of a network of
already existing extension officers and primary
schools in combination with the use of radio
programmes and mass-produced printed materials,
was able to operate for about US$ 0.10 per group
member. i’his is an example of the radical savings
which can be obtained through a careful
orchestration of mass media, mass organization
and small groups. With smaller numbers of
the costs are higher, but still
attractive. The campaign in 1971, which reached
about 20,000 participants, cost US$ 0.56 per
5. Grassroots political structures were strengthened.
The campaign was a cooperative effort by several
ministries and the political party, TANU. In areas
such as Dodoma or Mtwara, where the campaign
was very enthusiastically
received, the study
group leaders were often the 10 house cell
leaders of the party. The effect of this was to
provide an opportunity for the house cell units to
have the kind of participation in local decision
making on which Tanzania is depending: people’s
in their own development, i.e.,
development with the people, not for the people.
6. The mobilization
of large numbers of people
necessitates an extensive administrative
network. The lesson of this
campaign, however, is that it is possible to use
already existing structures, such as an agriculture
or community
development extension system,
providing these personnel are given some training
in the new methods.
7. A centrally-planned campaign has some dangers.
There are always dangers in a centrally-planned
campaign that the educational content will be
seen by both the planners and the people
themselves as something which is not to be
questioned but merely acted upon. There are
many examples of health and family planning
campaigns which merely pump the message into
the heads of the people and expect results.
Experience from the “Man is Health” campaign
indicates that the number of campaigns which can
be effectively done on a national level may be
limited. The information which is presented needs
to be of such universal concern to those taking
part that it will stimulate their own analysis and
they will thereby act in manners appropriate to
specific local situations. There may not be many
subjects which can by universally applicable.
There is no reason why these same approaches
could not be used at a regional or even smaller
8. An effective mass campaign in rural areas needs
the coordinated efforts of all the agencies and
ministries concerned.
Without the coordinated effort of rural development officers, health education officers, adult
education officers and some voluntary agencies,
the results of this campaign would have been
much less possible.
Good health depends on more than the attention
of the health officers. It means consciousness
raising, assistance with construction skills, even
increased community production in order to have
the necessary cash to buy such items as window
Effective rural
or malaria tablets.
of any kind needs a frontal
approach rather than a single sector approach.
As the study of the campaign continues, it is
hoped that the more detailed examination of
factors contributing
to the success of the
campaign can be isolated. It is also hoped that
some of the most important factors in planning
similar campaigns can be indicated. Clearly this
type of development effort has potential.
A lot has happened in Tanzania since the 1973
health education campaign described in this study
saw the
took place. In 1975, the country
of a five-year literacy campaign that
raised the literacy rate from roughly 25% in 1970 to
75-80s in 1975. This gain represents one of the
most stunning educational achievements in Africa
and an achievement that has taken place in a nation
that is listed as one of the 25 poorest countries in
the world.
1975 also saw the mounting of another mass
campaign on food production and nutrition, the
“Food is Life” campaign. (An excellent description
of this campaign was written by the Director of the
Institute of Adult Education, Fr. Daniel Mbunda,
and is available in the first issue of the Tanzanian
Adult Education Journal.) The “Food is Life”
campaign was, in many ways, more complex than
the campaign described herein, since food habits and
growing patterns vary from location to location. As
with this camoaign, there was a strong emphasis on
practical achievement. Preschool community feeding
programmes, workers’ canteens, and widespread
development of gardens were some of the results of
the campaign.
In November 1977, the Ministry of Education
announced the achievement of universal primary
education .. . a place for every boy and girl to attend
school. The method used to accomplish this goal
was to take the lessons from the mass campaigns for
health, literacy, and other aspects of political
education and to apply them to the task of primary
education. The communities
built the schools
themselves with their own skills and, largely, with
their own funds. The teachers have been, and are
still being trained through a combination
correspondence education, face-to-face instruction,
and radio lessons - methods first developed to reach
the broad adult population.
What about more mass campaigns ? The situation is
not completely clear. There are some in Tanzania
who feel that iarge%zaie campaigns divert resources
and energies for programmes that produce shortterm gains. But there are others who counter by
saying that campaigns have demonstrated a capacity
for doing what cannot be done in any other way and
what is needed is the better linking of such
large-scale efforts with ongoing programmes. Two
topics for further campaigns, the role of women in
development and the use of appropriate technology,
are being discussed in 1978. Whatever the decision,
the programmes that are adopted will be carried out
with considerable boldness.
The campaigns and the successes of adult education
programmes, along with other accomplishments in
Tanzania, are announced with a combination of
fanfare and humility. 9ut they should not be seen as
models to be picked up and used. There is much
room for improvement, much need for criticism,
and great cause for a continuing struggle. Nor should
this paper be used as a blueprint. It should, instead,
be seen as the presentation of materials for
discussion and reflection.
1. Hall, B. and Dodds, T. Voices for Dewlopment:
Tanzanian National Radio Study Campaigns. International
Extension College, Cambridge. 1974.
2. Colclough, M. and Crowley, D. The People and the P/an;
A Report of the Botswana Government’s
Project on the Five- Yeer National Development
Department of Extra-Mural Studies, U.B.L.S. Gaborone;
Botswana. 1974.
3. Hall, B. and Zikambana, C. Report on the Mtu ni Afya
Institute of Adult Education, Dar es Salaam,
Tanzania. 1974.
PART 111
Development planning has traditionally been .focused on methods of increasing production in order to
increase the GNP (gross national product) of a
country. Only recently have planners begun to think
that people and not products should be the focus of
improvements. Because cost-benefit analysis fails to
provide tools for planning for the development of
people, many have taken an increasing interest in
education. Rejecting the traditional teacher-student
formal institutional
approach, thev have centred
their attention on non-formal education. Essentially,
non-formal education stresses the process by which
adults change their attitudes and, eventually, their
own behaviour. Owing much to the thinking of Ivan
lliich and Paolo Freire, non-formal education denies
the imposition of a Western industrial model and
searches for way to bring positive change to
communities within their own culture and value
system The importance
of this process in
supporting a community participation strategy has
already been mentioned by Hall (see chapter VIII).
In this section, we examine the critical dimensions
“I-+ this prxess and their nzlevance for involving
people in taking responsibility
for their own
Because this process is not necessarily ‘related to
health care, although health may be a good entry
pcint, one of the two pieces in this section analyzes
some of the more general but very critical aspects of
change. Both essays, however, do address questions
of the necessity of changing the traditional
approaches that outside planners take to a
community. They deal directly with the problems
and practicalities of a people-focused development
ln the first article, Andreas Fuglesang explores some
of the reasons new knowledge is accepted or
rejected by people living in rural areas. He looks at
communications in terms of an educational process
and suggasts ways in which it enters or remains
outside people’s internalized thoughts. In doing so,
he analyzes the structures of a community and helps
us to understand how these structures, firstly,
influence community
reception to change and,
finally, influence change itself. It is a study of the
interface between community
community action.
The second selection, written by David Werner, views
?he aspects presented by the previous authors in a
health-specific context. Based on his experience of
eleven years in a Mexican village and his recent
travels to assess community
in a
variety of health programmes throughout
America, Werner illustrates the results of the Freire
approach to the educational process. His matrix of
programmes” shows how and which processes help
wider development in health care.
Andreas Fuglesang
It may be that there is ultimately one kind of
development only and that is development of
consciousness. Adult-literacy
programmes, agricultural extension work, health education, etc., are
maybe just different angles of approach to the same
basic goal. There are many paths to the centre of the
I have never liked the concept of the extension talk.
It is a great mistake to think that something is
happening just because you see somebody standing
talking in front of a group of villagers. I am not sure
whether I am any better off with the idea of
community therapy. I may lead the reader to think
that I consider the village community sick. Far from
it. What I mean is that everybody, if they want to,
has the right to get rid of the sickening bitterness of
a lowquality
life. i shall develop this idea in the
following pages.
Figure A
Figure B
When a stranger from the Western world or a local
townsman looks at a village, he sees something Itke
this: a number of houses, individuals
or entities
grouped together in space (Fig. A). It is here that
the observer
makes the first and fundamental
mistake, He superimposes
some basic experiences
fmm hir. own aclti~ty on his perception
2 .I,,
by increased individualization
the former in the general approach
and attitude
to life and the latter in the work
routine. Both are definite prerequisites for development of a technoloqica!
society. All development
It moves from the general to the
specific, for exarnple, from the all-round farmer to
the man who does nothing
the whole day but
determine the sex of chickens.
This process of individualization
and specialization
is also responsible
for an emotional
which seems to be unique to the citizens of the
society and which reclularly crops up
In modern literature as the crisis of man: the feeling
of betng alone In a crowded apartment
house, the
fact that you don’t know the chap in the flat next
door; the problem that nobody visits you, bpcaust>
relatives and friends are all llvlng far away o: do rlor
want to
In short,
just as a
be set upon during an evening stroll; the
to be somebody,
that you are
the identity problem (who am I actually? ).
the fact that modern society is experienced
number of individuals.
As a logical consequence
of this, the extension
worker, the local professional.
the “ewnert”
or the
“I I LC=_c! perce:ve$
fi iiTiSeii
as somebody
who is
supposed to con-:mt;nicate
with, and influence,
number of indiviauals
living in these village houses
to like a defined
and desirable type of action
(Fig, B). This is the extension-talk
approach, the
preaching approach. This is also exactly the opinion
and the attitude of “the Establishment”
and this is
the second fundamental
mistake we make in
work. Just listen to the glossy
modern terminology:
are going to hit them), MESSAGE DESIGN (with
bullets). MULTIMEDIA
(in a machinegun), CONSENT ENGINEERING
!and make them
surrender). We cannot get on with the work until we
realize that this approach
IS completely
linked, as It IS, to thr archaeuloyy
of commiini
cation: the Pavlovian stlm~lltr~‘response
model (cdl1
It the message mtlclt~l ), thtt st:r;rft!r r(‘c1pl~~rlt rnodrl,
the action modt!l or whatevtlr VIXI II~(:
It>forn>dt1or1, n~,~ssmt~ci~,ror t~x~~~rl~~or,f1tll(j
,111 (‘kIrrtr11!,oI
t t1 I'>
Figure C
cations thinking,
so that action is based on the
that a defined information
input automatically leads to a defined response. I have pointed
to the fallacy of this model before and there is
reason to expand on it here. Communication
perform a lot of verbal magic over the professional
top hat and let loose dozens of rabbits in their
just because they look so good on
paper. The deception in these fine words is that we
think we can work with a high degree of operational
control and precision.
There are two other rabbits which are a bit harder to
Whose image is the extension
What social detergent
is he an agent
All this one-way thinkina
is simoly a little
embarrassing. There is no humaneness in it. Besides,
it puts professionals
in the villages in a very
they are usually
aware of it. They are led to believe that they are
more than the villagers.
educated. They are specialists. They have mastered a
subject field, in contrast to the villagers who only
possess knowledge of a general character.
Their experience
of the modern
society is that the
because of their
professional competence. Their advice is listenad to
more or less automatically.
Not so in the village. The
worth nothing until he can prove his worth
on a purely human basis. That involves two-way
It involves
It is,
more important
that people in the field
are good listeners than that they are good talkers.
What else is a village but a nurnber of families?
It is,
in a very real and true sense of the word, the fact
that people live in a community
with each other.
They live in COMMUNION.
If you stay for a while
in the village and have some skill in observation, you
will realize that to live in communion
is very
from living in a block of flats. Life is
and illteraction.
If you are a very
patient observer, you will, as time passes, find that
is a set pattern
in the communication
activities. We can, with some justification,
say that
is an
in operation
(Fig. Cj. You will observe
that people are walking
in .lnd out of certain
people’s doors more often than they do with others.
They are seeking out some people at the mwtinq
place for a talk more otter), and spending more time
with them than with others. The pattern is stable,
but also somehow alters dynamically
with time and
and with subject matter. To my mind,
there is no doubt that this internal communication
system, to a very large degree, determines
and actions
of the individual
in the
The individual
is, first and foremost, a
group member. The internal system has a normative,
steering effect on his decision making. The villager is
not individualized
to the same extent
as his
educated counterpart
in iown. His decisions are not
to the same extent his own decisions. An illustrative
example I met with was the young woman who had
five children and wanted no more. The question was
whether she should have a loop inserted. But the
problem was that it was not her decision. Nor was it
her husband’s decision. It was the grandparents who
had to take the decision,
because they had,
to the tribal
rules, the right to the
ff we look at the community
in a wider context, we
shall find another
very significant
trait from a
of view.
Figure D is an
attempt to picture proportionately
the co;nmunication contacts or exposures. There is intense internal
in the family
units and between
them in the village communities;
there is some
between various village communities, and relatively
little communication
with the
outer world. Anybody
who lives in a village for a
while is capable of observing this phenomenon
some of its more unpleasant
outer world is represented by the presence of mass
media, often in a variant of a vernacular
which is not fully understood,
the odd relative or
friend who has been to the big city, but whose
as an information
source is not exactly
objective, and the government
who comes
and disappears in a Landrover duststorm every now
and again with annoying queries, forms to be filled
in, and promises. Afterwards
nothing happens, and,
if it happens, it is only after a very long while. When
will officials and professionals realize that there are
too many surveys and too little action?
In my
the village community
has e.ery reason
to be suspicious of the outer world. There is lack of
and lack of knowledge, but there is
also bad experience.
These conditions
impair to
some extent the ability of the villager to evaluate
from outside
in a reasonable
Above all, it makes him evaluate the credibility
messages on a scale on which those
from outside are considered less credible than those
from the immediate environment.
As we shall see later, this has consequences for the
policy in development programmes.
The villager sometimes feels inferior to the stranger
from outside and he fears him. The village yossip can
very soon make the stranger a monster. But, as a
whole, the village people’s capacity, including their
is grossly underestimated.
hurts to be “underdeveloped”.
cannot succeed unless there is a
sincere feeling of equality
in the system. This is a
premise which cannot be repeated often enough.
Firm E
Figure E may illustrate the mess of conflict which
arises when the artificial message model communication system, the extension
preaching approach, is
superimposed on the natural one in the community.
The professional’s
messages are colliding all the timf
with the massages which are already floating in the
internal system. The former type of message is the
and scientific
based on a rationale.
The latter is the traditional
based on authority
and experience.
I fail to see any distinct
personally, there is undoubtedly
sometimes conflict
in the factual content of the messages of the two
systems. When the agri,zultural
explains to the farmer that he must lay the plough
in a certain
on the
it may well be better applied knowledge
than the traditional
way of ploughing in a criss-cross
fashion. But one must not always take that for
granted. Traditional
not have
survived through
the centuries,
if it did not have
certain merits.
One tribe used to scrape a certain mould off rotting
trees and apply this to infected wounds. The health
It was harmful
until he saw the healtng effect
It was later
Nor should
one underestimate
farmer’s professional
judgement as the agriculturist
he after all is. The new plough with a steel share
may be better than the traditional
one in normal
soil. But in certain types of hard soil it is not
pointed enough and the angle of the share is too
steep. The result is that the new plough bumps and
the farmer can, with justification,
maintain that it is
more awkward to use than the old one. But the
possible conflicts
of the communication
cannot be referred to the factual concept alone.
have reference
also to the fundamental
attitudes behind the approach to reality of the two
are centres
of gravity
in the internal
system of the community,
as I have
earlier: people whose advice is sought
more often than others and whose statements about
are listened
to, even
if they
asked for, etc. A word which is often used about
such people is OPINION
(Fig. F). We
know that they are there
The problem
In practice
to Identify
The rtssrntl~l
oorrlf 15 thdt they
PJI’~ tht. slrt)lvc!
morP offPI
* ff,r’,
i T ‘!;,
‘3 I
may and it may not coincide
with the formal
of the community.
The chief or the
village headman may be the definite opinion leader
in matters related to marriage quarrels or land
disputes but in other matters he is not. The opinion
leader concept may be seen also in relation to the
idea of “shared interests”.
In a village I visited, the
opinion leader in all matters related to the town and
news from and about the town was an old house
servant who had lived in the capital for many years.
All incoming
news was checked with
him for
In another village, the opinion leader in
was a middle-aged
progressive farmer.
The local party branch secretary is very often the
village spokesman in reiation to government, at least
in countries where there is political movement in the
rural areas. It is necessary to realize that the
of opinion
leaders derives only partly
from the fact of their specialized knowledge.
and the authority
of their
seem to be of great significance
in the
eyes of the community.
the emotional
experience of exposure to authority
is probably the
same in modern society as in the village community,
there are some differences
in the premises for
which we should have a look at.
This is an extreme
it carries some essential
is Important
the “exprt”
but, in my
trutns which It
or the local
to be aware of, if he is going to
a working
with the village
This is the difference in attitude to life.
I have earlier touched on the problem of authority.
have over the years witnessed one “expert”
another falling into the same trap. The question of
is absolutely
vital in any communication
because it stands for the credibility
of the
message in the eyes of the other party.
In the modern industrialized
society, authority
delegated downwards
in a hierarchical system. The
next model (Fig. G) also illustrates
the principle
is a differentiating
moving from the general to the particular.
So the
of the specialist
or “expert”
does not
derive from himself but from his position
in the
system. It is the system which entitles him to take
decisions for other people, makes them obey his
orders and listen to his advice. Not so in the village.
The “expert”
or local professional ~who bases his
work on that assumption
is hard up, and many do
that, unfortunately.
As I have tried to illustrate In Figure G, the concept of
seems to have another dimension
in the
village community.
there are, of course,
structures on the national or tribal level,
a person’s authority
In the wllage does not derive
from the fact that he IS “hqh up” II IS ,? a way
more connected wl!h rk Idea of kwtrjg “e*ar+ar ?O !he
l .
centre of attention,
both in a spiritual and physical
sense. That picture is sometimes even reflected in
the spatial layout of the village. Authority
in the
is derived more from the person than
from the syste’m. It radiates from performance
In a hostile
in which the individual
can survive
only as a community
member, the centre of the
group circle has a deep significance,
but so has the
The centre is protected by the periphery
and keeps it together
at the same time. The
is dynamic;
the centre today may be
to periphery tomorrow.
The tale of the
great hunter is still very much alive. The “expert”
from outside has to understand
Figure H
I A,
to our original
model, we may now
perhaps see that the art of applied communication
in community
which is already in function.
other words, the community
educates itself and the
or field
ideal “expert”
presence as much as possible. The
is the
village teacher, the elder A or whoever
relevant ‘opinion
leader becomes instead instrumental in relation to the community
(Fig. H). The
approach certainly has its danger. It requires a high
degree of maturity and judgement on the part of the
field worker. He may very easily ally himself with
the wrong
people in his working
in the
Therefore, initially,
his problem is not a
but a purely human one. He has to go
what can be suitably
called his INITIAT1ON period, the period of reading up and listening
in. Acquiring
of the local
custnms through the available literature is essential
and living in the village no less essential. If the
could go to his initiation
with the same
humbleness and sincerity
as the youngster
in the
Lunda tribe
in the North-western
Zambia goes to his WUYANG’A
ceremony, it would
be very good for his future work. There are stages in
the development
of a good communicator.
there is the KUWELA
(“to wash oneself”):
to be
clean and ready, free from preconceived opinion and
prejudice. Then there is the KU-SUKULA
to huntmanship”):
the moments
of sensitivity
and listening, when the budding hunter is under the
of experience,
in the great
hunter who teaches him the bushlore, the practical
of the objectives.
there is the
KU-TEFEKSHA (“causing to cook”), in which the
hunter kills an animal and provides a COMMUNION
MEAL for an assembled company of hunters. This is
the fiery ordeal, the test of his maturity, judgement
and personal performance,
and his acceptance as an
equal in the communication
But there is a certain prerequisite
which must be
in the
of the issues of the development
programme the “expert”
or field worker is working
for. This is the function
of the growing mass media
like radio, TV, vernacular newspapers, etc., whether
the issue is family
something else (Fig. I).
it is necessary to look at the media
concept in a much wider sense. It is a question of
An information
medium, therefore, is any
vehicle which can carry a message. Some development issues, like nutrition
and agriculture,
approach; others are more limited in r:ieif ZU~Z.
But it is, in any case, all a matter of pragmatic
with the reality of media opportunities.
In most developing countries, the school system is a
major medium. Adult literacy programmes are the
same. The extension
services, ranging from agriculture to public health, are also media which can
carry messages related to their objective.
On the
are a variety
of media
with origins in the traditional
have hardly
been discovered
as yet. In
Nigeria, touring companies of traditional
actors have
been used in family planning promotion
and film
In Ghana, the market women represent
a social
Local comedians, storytellers
singers are channels open to utilization.
The creating of awareness is the standard information approach and will not be detailed here. The
secret is to work
on a national
basis, partly
committees, etc. and partly INFORMALLY
through direct
mail contact and other informal
channels to the
people in the field, ranging from primary school
teachers to chiefs and district officers.
Awareness in the community
of the development
issue concerned is a prerequisite for any later stage
of field work.
has vast implications
for the
selection and training of field workers. The selection
must be based on personality variables like attitudes,
and on performance
in groups and similar criteria.
The training
must advance from being only the
of cognitive
from one brain
storage to another to being the development
skills. Communication
exercises and
become keywords.
The knowledge of the development
issue itself
is really
sometimes of secondary importance.
This is not the place to go into detail regarding this
issue. It shall be mentioned only that there is now
the field, an elaborate practical
It is possible through exercises and
staged learning experiences to sensitize field workers
and other communicators
to the feelings and needs
of their recipients and to develop their consiousness
and ability to analyze human interaction.
This is, to
a large extent, just a matter of restructuring
staff training programmes and defining
them in closer relation
to simple performance
What do we want the field staff to do
with their knowledge?
How do we train better
An excellent introduction
to the
of Staff Development and
is “Handbook
Human Relations Training: Materials Developed for
Use in Africa.“’
But the problem of better communication
with the
village community
can ultimately
be solved only by
a commitment
to equality on the human level.
Some more should be said of the field
in the community.
What about the “expert”,
the volunteer,
the local
the field worker himself: how can he
How can his
and advice be present in the internal
system while he is standing outside
The answer, communication-wise,
is to advance
from awareness to CLOSENESS,
In my experience,
closeness depends on two main factors. Firstly, it is
as a
human being, his personality,
his ability to identify
with the community,
and above all, his SENSITIVITY
in human relations. Secondly, it is a matter
of a certain level of cognitive knowledge, as I have
mentioned earlier, of local customs and beliefs, but
also of group dynamics, percepti,n
related fields.
In the development
of consciousness, nobody is the
teacher. The teacher is just one of the group (Fig. J).
The group
is teaching
It cannot
be an
objective to transfer knowledge and values from a
group in society which is powerful to groups which
are less powerful.
It is the dialogue between groups
can bring society
and it is the
dialogue which is the tutor in the circle. Each man
and woman is a creative being who has knowledge
and experience of value for the development
of the
and society at large. It is a complete
that village people are ignorant. They
just have another type of know!edge.
To help people to become conscious
of their
as creative beings, to make them see that
they can control their environment
and themselves
in a better way, is the task of the field worker,
whatever his professional starting point. Regarded in
this way, his work is communrty
therapy and as
such, depends enrrrely on hts ability to BE, Ilterdllv.
IN TOUCH with the community
(closeness). How
do the villagers conceptualize
their world? The field
worker can come to understand that only by being
to “live
But, without
using as a measure stick the
he is born with himself, he must
nevertheless be clearly conscious of that conceptualization
all the time. We can understand
people only by understanding
them in relation to
ourselves. To identify
the internal communication
system and, above all, to identify the community
it expresses itself in its use of language becomes the
field worker’s immediate task.
I shall mention
and recommend
reading two recent reports which are both very
of the points which I have made in the
preceding pages on a communication
strategy in the
Karl D. Jackson and Johannes Moeliono presented,
Irl October
1972, an investigation
on communication
and national integration in Sundanese villages in West Java. In their
which is based on the documentation
thorough!v quantified data. they state, amongst other
and new communlCd
flashy. prest~gzous, expenstve
tion alternatives,
strategists should
aim for maximum,
change in
the villages.
In Sundanese villages, this implies
the use of traditional
networks to amplify the effectiveness of administrative and mass media communication.
Policy planners
must resist the all too natural tendency to adopt the
newest hardware as a means of avoiding the much
more difficult
job of connecting
existing hardware
and administrative
with the traditional
leadership structures at the local level.“*
That the practical problem is the link-up between
the mass media and the personal
is illustrated
also In a report on a
mass communication
campaign undertaken
in the rural areas and small towns of India by
Ronald Parlato et al. (February 1 973).3 The authors
realize, as in many other similar investigations,
the capacity of the mass media is limited to the
creation of awareness and understanding.
Feeling the missing link between knowlet’,:
and behavioural
change, they conclude by pointing
out the necessity of integration:
segments of the population
becoming aware of a
new idea and understanding
it fully. no extension
agent can operate effectrvely.
Wtthout the credtble.
“‘/Ill ‘,“‘,‘1”
1,!, ’ :I’,,
These two practically-oriented
reports are worth
study by any communication practitioner.
1. D. Nylen, J.R. Mitchell and A. Stout, Handbook ofSfaff
and Human Relations Training: Materials
for Use in Africa.
edition, Washington, 1967.
Revised and expanded
2. K.D. Jackson and Johannes Moelino, Communication
National lntegra tion in Sundanese Villages. Implications for
Strategy. East-West Center Communication Institute, Honolulu, 1972.
3. R. Parlato et al. Breaking
Care India, 1973.
the Communications
David Werner
Permit me to begin with an apology. I am not a
medical professional. My experience lies in grassroots medicine in Latin America. For the past eleven
years, I have been involved in helping foster a primary
health care network, run by villagers themselves, in a
remote mountainous sector of western Mexico.
During the past year, a number of my coworkers
and I have visited and studied nearly forty rural
health projects, both government and private,
throughout Central America and northern South
America (Mexico, Guatemala, Honduras, El Salvador, Nicaragua, Costa Rica, Ecuador, Colombia and
Venezuela). Our interest in these programmes grew
out of the widespread use of Donde No Hay Doctor
as a training and work manual for primary health
workers throughout Latin America. Donde No Hay
Doctor (Where There is No Doctor) is a villagers’
medical handbook which I initially wrote for use in
our programme in the mountains of Mexico. Our
objective in visiting different village health programmes has been to help foster a dialogue among
the various groups, as well as to try to draw together
many respective experiences, insights, methods and
problems into a sort of field guide for health
planners, so that we can all learn from one another’s
I would like, on this occasion, to look at rural
communities, and to explore with you the ways in
which existing health programmes help either to
cripple communities or to make then1 whole.
were countless remote villages that, for better or for
worse, stood on their own. They had their own
medicine men, midwives, bone-setters, tooth-pullers,
psychic healers and priests. Life in these villages was
at times hard and at times gentle, at times lorg, too
often brief, but it was fairly much in balance. The
village community was a more or less complete
largely self-sufficient
with the pride,
integration and dignity that come from self-reliance
and self-direction. Then came that new magic, that
new mystique - Western Medicine - with its
esoteric priesthood of university-trained
practitioners. Their renown and their wonder drugs, if not
their physical presence, quickly spread to the most
remote jungles and mountain valleys. In spite of
attempts by the medical profession to legally
sanctify its stronghold over prescription drugs, a
clandestine market sprang up. Soon, folk healers,
bone-setters, midwives and mothers had added
and a range of other
pharmaceutics to their gamut of herbs and home
remedies. A new breed of “modern” folk healer, the
medico practican te, or empirical doctor, arose,
assuming ;e
,, , the viilages zhe same role of self-made
and prescriber-of-drugs
that the
neighbourhood pharmacist has assumed in the larger
towns and cities. The magic of the injection held
special power over people’s imagination, and soon
nearly every remote village had its inyectadoras Or
women who inject.
The idea of a health care project or programme
being a crippling force may come as a surprise. Yet,
as I will try to clarify, to whatever extent a village
health care service creates a one-way dependency on
outside resources and directives, it becon?Zs a
crippler as well as a crutch to the community.
Needless to say, the abuse and misuse of modern
medications by this army of empirical healers have
been enormous (as, in fact, have been the misuse
and overuse by the medical profession itself! 1. Yqt
the net impact on morbidity and mortality has beelo.
at least from a short-sighted perspective, positive,
With the introduction of antibiotics,
and to a lesser extent, vaccines, fewer children have
died of infectious disease As the populdtlon has
as eisewhere,
has been a tve*oedqd sword hi!;! ‘::nq ago ?he’?.
tn, gr~i:~Pg
tncreased, the crlppllnq
ImWCt Of
has qc,~w i~frt; ;->:: VT-47 [,~,vI!
[)?r’,s .r:*s ‘,j’ i,&.() ,,‘,. ,;I .“.. ’ .’ : , ’ .
of land tenure and distribution
of wealth have
become more oppressive. As a result, rural
communities which once were self-sufficient and
proud have come to depend more and more on
outside help: for medication, for food supplements,
for education, and - most demeaning of all - for
values and direction. In response to the growing
plight of rural populations, the political/economic
powers-that-be have assumed an increasingly paternalistic stand, under which the rural poor have
become the politically voiceless recipients of both
aid and exploitation.
This state of concomitant aid and exploitation still
dominates the health care picture in much of Latin
America today, as it does in many parts of the
world. The medical empire has geared its services, its
medicines and its hardware (even its textbooks) to
such tremendous profits that it has, in large part,
priced itself out of reach of the majority of the
people, thus making subsidized services the only
obvious alternative. Compounding this dependence
on charity is the fact that, in Latin America, the
to serve
professionals, although rarely willing
communities where the needs are greatest or to
work for an income that will truly serve rather than
bleed such communities, have been notoriously
reluctant to share their knowledge or rights-topractice with members of these communities who
are eager to learn and who would willingly serve
their people’s health needs, voluntarily
or for
modest remuneration.
When we asked the pioneers of rural health
programmes we visited in Latin America what they
saw as the major obstacles to bringing effective
health care to the people, the most common replies
wre “doctors” and “politics”.
However, over the past decade, a change has been
underway. There has been a general awakening, or at
least the beginnings of an awakening, to the need for
a more realistic, more truly equitable approach to
health care. The trends which have been taking place
in this recent renaissance of health care are
summarized in Outline 1.
The overall trend, at least in theory, is from a
fragmentary to a wholistic approach to health
care. It involves a shift from providing
curative services to a select few, to providing
preventive and curative care to as
many of the people as possible and, ideally, to all.
To do this, the concept of the health “team”, or
skills pyramid, has been introduced, of which the
basic work force is composed of local, modestlytrained village health workers, often referred to as
promotores de salud (health promoters). In some
programmts, the base level of the health team or
pyramid is considered to be composed of mothers
and schoolchildren - whose collaboration as health
workers is fundamental - or the base line of the
health team may, and I think should, be regarded as
the community itself.
Perhaps one of the most important trends, but one
we found actually happening in relatively few areas,
is the effort to have more and more of the skills
pyramid filled by local members of the rural
community, and progressively less by outsiders. One
programme in eastern Ecuador, working with the
Shuar Indians, has set its goal to eventually replace
all its field professionals nurses, doctors,
veterinarians, agronomists and even legal counselors
- with persons from the Shuar villages. The
programme is providing the necessary scholarshi$
and encouragement. Whether or not the chosen few,
once they get their degrees, will return to their
villages and work for the modest earnings the
can afford, is yet to be seen.
Unfortunately, our formal education systems do far
more to wean people away from the rural
environment than to prepare them for staying there.
New ways need to be explored, and new education
opportunities designed, which will allow villagers to
specia I ists
from outside
the community
med. students/new
dllk llldflf?5
,,I. r.s ‘*,I ~
P,: !:,j~,,, r
!‘. .
substantially increase their technical knowledge and
skills without
tearing them away from their
As is indicated in Outline 1 under “Focus of
Action”, there has, of course, been a trend in rural
health care not only from curative towards preventive
medicine, but, by taking into account the causes
behind the causes of poor health, towards the
integration of health care with other aspects of
community development. Hence, the most recent
trend is now to include health care as but one sector
of an Integrated Development Programme which
also covers education,
agricultural extension, communications and marketing improvements, intermediate technology, etc. In
fact, some of the most exciting work we saw, with
the greatest impact on the health and vitality of the
communities involved, had its major thrust in
agricultural extension rather than on health care per
se. In one programme in Guatemala, sponsored by
Oxfam and World Neighbors and focusing on
agriculture, the resultant increase in food production has not only directly improved the nutrition
and health of the people, but has generated an
income which has permitted the community to
cover costs of other improvements rather than be
dependent on outside help.
If integrated development is to be taken seriously,
and if a programme is really trying to confront the
underlying issues which affect the health, well-being
and future of a given people, it must, of course, take
into consideration
the sociopolitical
including the debilitating influence of paternalism
and exploitation. Such considerations have led some
rural health projects to work through group
dynamics to promote conscientizatim
or social
awareness and to become involved with land and
social reform. However, many of the groups we
visited in Laltin America would have nothing at all to
do with such politic#ly
“hot” issues, either because
they didn’t dare to, or because, for obvious reasons,
they didn’t care to.
However, even if a programme does not touch upon
issues of land reform or social justice, even if it does
not hold discussion groups to encourage conscientiration, if it is truly trying to help the community
stand on its own feet, issues of social injustice and
land inequity will eventually come up, if indeed
they are limiting factors to people’s well-being. This
can be a serious consideration in nations where 10%
of the populace owns 90% of the land and wealth.
And it can be a serious consideration for foreign or
international health and development agencies.
Perhaps the key question, then, is whether the
outside agent-of-change, or sponsor - be it a private,
religious or government group, be it domestic,
foreign or international
- really Hlantj. of can
to have
afford, to allow rural communities
substantial choice, or voice, in matters of their own
As is indicated at the bottom of Outline 1, another
of the recent trends in rural health care has been a
shift from many small pilot projects operating in
circumscribed geographic areas, to large regional or
even national programmes. Many of the early
attempts at community-based health care, including
the training of village health workers and cooperation with traditional midwives, were launched by
groups, many of them
private or religious
(American, Canadian, British, German,
etc.). Throughout Latin America, there has been a
proliferation of these “pilot projects”, some of them
successful and enduring, others appearing and
disappearing, here and there, like fireflies. Often
there has been a lack of communication
between nearby projects, and sometimes a not-sohealthy competition.
However, some of the most
and effective community
observed is being fostered by small non-government
projects. One of the key questions today is if and
how such activity can be replicated to reach more
people. As a foreign consultant in El Salvador puts
it, “We’ve had enough pilot projects. It’s ti;. ? we
stopped reinventing the wheel and got busy helping
it to roll! ”
And so we find that on the heels of the many
private and religious Iprojects, and sometimes
nipping at their heels, bars come a wave of regional
or national programmes administered by respective
ministries of health. Today, nearly all the countries
of Central and South America are engaged in
launching or expanding “community-oriented”
programmes incorporating
the use of
health workers and the so-called
“control” of traditional midwives.
Surprising similarities exist in the format and
details of many of these different
government health programmes; surprising until one
realizes that nearly all of them are aided and
monitored by the same small complex of foreign
and international
agencies: WHO/PAHO,
IDRC, IDB, UNICEF, FAO, Millbank Foundation,
Rockefeller Foundation, Kellogg Foundation, etc.
Often, a single health or integrated development
programme will have financial or advisory input
from as many as three or four of the above agencies
or foundations.
An entire jargon has evolved for those who are
“hip” on community-based rural health care. From
country to country, one hears identical motifs, e.g.:
“Primary decision making by the members of the
“Response to the felt needs of the
“The primary health worker chosen
by the members of her community”,
must be determined by the comrnunlty It&f”
r&as behmd these axioms are. of course. [email protected]
tal. But, too often, they are as foreign to the
communities they are aimed at as to the health
ministries on which they have been superimposed. If
there were a little less rhetoric behind these slogans
and a little more reality, the state of rural health
care in Latin America might be far better off than it
is today.
In our travels through Latin America, we were struck
hy the fact that often the policies or activities of the
many different health programmes we visited tended
to fall somewhere along a continuum between two
diametrically opposing poles:
1. Community-supportive
programmes or functions
are those which favourably influence the long-range
welfare of the community, that help it stand on its
own feet, that genuinely encourage responsibility,
initiative, decision making and self-reliance at the
level, and that build upon human
2. Community-oppressive
programmes or functions
are those which, while invariably giving lip service to
the above aspects of community
input, are
paternalistic, or are
structured and carried out in such a way that they
actually encourage grea?er dependency, servility and
unquestioning acceptance of outside regulations and
decisions; those which, in the long run, are crippling
to the dynamics of the community.
In Outline 2, I have tried to summarize some of the
various features of rural health programmes, and to
point out how different approaches tend to make
each feature either community-supportive
or community-oppressive.
I do not ask that everyone
necessarily agree with me on every aspect. Often,
the differences in approaches turn on “human”
factors such as dignity and caring, which are hard to
measure yet are, in my belief, immeasurably
important. This outline, then, is intended primarily
as a guide (or perhaps goad) to stimulate those
involved in the planning or process of rural or
periurban health care to think through each aspect
of their programme and its policies in terms of what
may ultimately be for the good of the community.
Needless to say, no health or development
programme will explicitly profess to be communityoppressive. Nor, in any of the programmes we
visited, did we encounter any in which every aspect
was either oppressive or supportive. In each there
was a mixture of streng’hs and weaknesses, as is
indeed human.
However, it is interesting and, I think, somewhat
disturbing, to observe that (with some notable
exceptions) the programmes which, in general, we
found to be more community-supportive
were small,
private, or at least non-government programmes,
usually operating on a shoestring and with a more or
less sub rosa status.
As for the large regional or national programmes:
for all their international
funding, for all their
highly-trained (and highly-paid) consultants, for all
their glossy bilingual brochures depicting community participation, we tound that, when it came
to the nitty-gritty of what was going on in the field,
many of these ambitious “king-size” programmes
actually had a minimum of effective commtinity
participation and a maximum of handouts, paternalism and superimposed,
Taking care of others
Helping others learn
Perhaps the biggest challenge today concerning rural
health care is: how can more people become
responsibly involved in caring for their own health?
Or to put it more explicitly:
How can the
features of outstanding, small,
pilot projects be adapted for
regional or country-wide outreach?
Attempts have been made. Results have, at best,
been only partially 5uccessfuI.
l would like to explore briefly some of the steps
which are being taken, or might be taken, to
a regional or national approach to rural
health-tare that is genuinely community-supportive.
To do’ this, let us focus on some of the major
obstacles or limiting factors.
1. Attitudes
It has often been said, in community health work,
that modifications which require changes in attitude
or in the traditicnal way of doing thing5 are those
which are accomplished most slowly and require the
most time and patience. Usually, such statements
are made in reference to villager5 or the
but, as many pioneers of
health care alternatives will testify, often those
whose attitudes and traditional approach are most
difficult to modify are not the villagers but the
professionals. Many regional or national health care
programmes which “draft” young doctor5 or nurSes
find many of them unable or unwilling to adapt to
working supportively with paramedics and village
health worker5 in the rural setting. Their training
not only does not prepare them for such
involvement, it actively conditions them against it.
A5 an example, let me mention to you two classes of
medical students, one first-year and one fourth-year,
who were taken, on separate occasions, to visit an
outstanding regional rural health programme in
Costa Rica. The first-year medical students were so
enthusiastic about the director’s portrayal of the
programme, with it5 “health circuses” and its
and -operated health posts, that
they questioned him for hour5 and finished with a
standing ovation.
By contrast, the fourth-year
students who visited were clearly bored, asked
almost no questions, and drove back to the city as
5oon as they could, without even bothering to look
at any of the health posts. These budding MDs
seemed to feel thenselves above primary care or
Their skills, and their
concern, clearly related to sickness, not health!
Qbviously, if doctors are to become part of a rural
health team, their schooling must be radically
different. It must have new content and a new set of
values. Above all, it must teach the doctors-to-be
that their knowledge is not sacrosanct; and that
their first duty is to share it. It must help them to be
humble. Some of the medical schools in Latin
America are trying to work towards these changes.
But many administrators and professors are still
firmly set in their attitudes. It will take a long time.
2. Hazardous emphasis on safety
There Seems to be a tremendous reluctance on the
part of health care planner5 to teach or permit
village health worker5 to do very much in the way of
diagnosis and treatment of common diseases. Many
programmes limit the curative role of their health
workers to the symptomatic treatment of only three
or four problems, such as “fever”,
diarrhoea”, “cough” and perhaps “worms”. Except
for aspirin and maybe piperazine, the medicines
they are permitted to use have little or no clinical
value. But, as is pointed out, they are “safe”. Such
programmes seem to ignore the fact that village
stores sell to anyone over the counter a wide range
of drugs - everything from chloramphenicol
vitamin B12 and pitocin - all of which are
commonly used and misused by the people. Yet,
because these drugs are “dangerous”, the health
worker is taught nothing about them: neither their
uses, nor their misuses, nor their risks. Hence, the
popular rampant abuse of drugs continues unabated.
What is more, the village workers’ trivial knowledge
of medicine, in a community where many medicines
are widely used, reduces the people’s respect for
them and makes them less effective, even in
preventive measures. We found that, in villages with
these insignificantly-trained
health workers, far
more people still used the services of medicos
practican tes - or self-made medics - than sought
assistance from the official health workers.
In Colombia, a health officer told us of a village
worker, or promotom, who, at a time when the
rivers were in flood and all transportation was cut
off, was called to see a child with acute pneumonia.
The health worker desperately thumbed through her
official Manual of Norms. But the only instruction
under “Fever with cough and difficulty breathing”*
to doctor”.
This being
impossible at the time, she referred the sick child to
the local shopkeeper, who at once injected the
youngster with penicillin.
Fortunately, the child
* The designers of the Manual of Norms
avoided “difficult
had carefully
llke pneumon,a,
that this and many other merhcal
~~I’IwS for dtseaws are a standard part of vollqe
Common to man) of th*le off5c~3: mawai~
I asked the health officer if perhaps promotores
working in such isolated areas should not be taught
something about pneumonia and the use of
penicillin, or at least be given a simple reference
book where they could look such things up. She
the health department’s
replied that, officially,
policy was that promotores administer antibiotics
only with a doctor’s prescription . . . and that it
would “not be good for them” to have a reference
book explaining things “outside their norms”.
To give another example, in many programmes we
found that, although village health workers were
perhaps taught how to attend a normal childbirth, in
the case of postpartum haemorrhage, their only
instruction was, once again, to refer the patient to a
doctor. Both uterine massage and use of ergotamine
were considered “too risky”. For health workers
living hours or days away from health centres, such
political over-precaution could, and surely has, cost
many lives.
Basically, what we often found lacking on the part
of the planner5 of these large health programmes
was a realistic perception of what really goes on in
the villages. Time and again, we found that primary
health worker5 were taught and permitted to do far
less medically than the villagers were already doing
for themselves. By contrast, many of the leaders of
smaller non-governmental health projects seemed to
have a much better comprehension of village life, as
well as greater appreciation for the ability and
potential of their primary health workers. While
helping their promotores recognize and work within
their limitations, they trained them in a far wider
range of skills. As a result, the health workers in
these programmes were more challenged, worked
with greater pride and enthusiasm, and, because of
their wider knowledge and skill, had the fuller
confidence of their people.
A programme which is truly community-supportive,
it would seem, must help and encourage both the
village health workers and their communities to
learn and function to their full human potential. To
do this, of course, involves certain risks. I refer to
risks for programme management rather than for
patients. Patient risk, in many cases, is actually
reduced by giving non-professionals greater medical
But to verify this, programme
planners and officials must be willing to stick their
necks out, to risk the slings and arrows of an
outraged medical monopoly. Risk must, of course,
be balanced with precaution. Yet programmes which
are top-heavy with precautions get nowhere.
3. Bureaucracy
Bureaucracy is the hobgoblin of giant prodrammes!
Red tape, excess paperwork, waste motion, wasted
poor communications
money, inefficiency,
ultimately, graft and corruption seem to inevitably
enter into the picture when operations get too big
(or, as one programme leader in Honduraq describes
it, when the superstructure overpowers the infrastructure).
The very large regional or national
programmes we visited characteristically
from breakdowns in communications, supervision
and supplies, sometimes to the point where health
workers became totally ineffective. One internationally-acclaimed regional programme we visited in
southern Mexico was so out of touch between office
and village that it was still sending paychecks to a
community worker who, six months before, had
monad to another village and was collecting another
salary from the Forestry Department.
The question is, how do you regionalize or
nationalize an approach to rural health care without
bogging it down in bureaucracy? For the answer,
which is simple but not easy, I think we might look
to E.F. Schumacher,1 and consider decentralization.
In a decentralized plan, the role af the ministry of
health could be to coorainate and advise rather than
to control and restrict. This would be true at all the
intermediate levels down to the community itself.
At every level, the maximum amount of self-sufficiency and self-direction would be encouraged. This
would not only decrease bureaucracy, but increase
personal irivolvementand responsibility at every level.
4. Commercialization
In Honduras, an open-minded director of one of the
regional health programmes referred us to a
curandero or native herb doctor who was acclaimed
for his healing powers. His fame for curing patients
not relieved by doctors had grown to the point
where he was invited to Tegucigalpa by an official of
the health ministry, who asked him, among other
thingsr why it was that with his people, modern
medicine was so often ineffective. The herbalist
replied, “Porque lo han comercializade?
” - because
they have commercialized it!
The problem of commercialization of health care is
many-sided. It has often amused me how some of
the big health programme officials, many of whom
Feceive salaries twenty to thirty times that of the
average villager, can talk to a community about how
important it is that the village health worker be
voluntary, working for the joy of helping others and
the personal satisfaction he gains from serving his
community. These officials always seem so surprised
and disillusioned when they discover that a health
worker has been selling medicines that are supposed
to be free, or is otherwise turning his “service to the
into a lucrative business. In truth, the
health worker is merely following the example of his
role model.
Here again, in certain of the smaller less formal
programmes, where many of the outsiders sometimes even the doctors - are voluntary or work
for minim1 wages, it somehow rings truer when
pople speak of service for the joy of it. In general,
doctors and other professionals not only cost too
much for rural or periurban communities, they earn
too much to serve as role models in community
health programmes which would purport to be
equitable. I can see no getting around tilis problem
until we can foster a new breed of medical
practitioner, who comes from the community he
will serve, and who is willing to serve his community
for modest earnings.
The other side of the commercialization
medicine, namely the flagrant overpricing and false
promotion of pharmaceuticals, I will only touch
upon. The alarming facts are painstakingly disclosed
in Milton Silverman’s new publication, The Drugging
of the Americas,2
and in other writings. Beyond
doubt, the unnecessarily high cost of critical
medications is one of the major obstacles to the
financial self-sufficiency of community-based health
activities. Honduras and Peru have begun their own
and low-cost distribution
of basic
medicines. Other countries would do well to follow
suit. I might also dare to suggest that, if the
international health agencies really want to give a
boost to developing countries, rather than hand out
more free medicines, they might pressure for honest
and fair pricing of drugs by the
multinational corporations, for amendments of drug
patent laws, and for other measures to bring
medicines to their users, not free, but at a price
nearer the cost production. (In case anyone thinks
this would make a smal! difference, I might mention
that in Colombia the hidden profits on Valium, for
instance, have run as high as 6000 percent).3
The commercialization
of medicine, and the
legitimized exploitation of people by other people
can perhaps be dealt with only through major social
change. Yet these problems do exist and can no
longer be ignored. Equitable health care at the
village level will surely remain a pipe dream in
countries where medicine as E whole continues to be
such a flagrantly profitable institution.
5. Politics
I have already mentioned
that politics are
considered by many to be one of the major
obstacles to a community-supportive
This can be as true for village politics as for national
politics. However, the politico-economic
of .che country must necc‘ssarily influence the extent
to which its rural healtl, programme is communitysupportive or not.
Let us considcc the implications in the training and
function of a primary health worker. If the village
health worker is taught a respectable range of skills,
if he is encouraged to think, to take initiative and to
keep learning on his own, if his judgement is
respected, if his limits are determined by what he
knows and can do, if his supervision is supportive
and educational, chances are he will work with
energy and dedication, will make a major contribution to his community and will win his people’s
confidence and love. His example will serve as a role
model to his neighbours, that they too can learn
new skills a?d assume new responsibilities, that
self-improvement is possible. Thus, the village health
worker becomes an internal agent-of-change, not
only for health care, but for the awakening of his
people to their human potential . . . and ultimately
to their human rights.
In countries where social and land reforms are sorely
needed, where oppression of the poor and gross
disparity of wealth is taken for granted, it is possible
that the health worker I have just described knows
and does and thinks too much. Such men are
dangerous! They are the germ of social change.
So we find, in certain programmes, a different breed
of village health worker is being moulded . . . one
who is taught a pathetically limited range of skills,
who is trained not to think, but to follow a list C$
very specific instructions G: “norms”, who has a
neat uniform, a handsome diploma and who works
in a standardized cement block healtt ,>ost, whose
supervision is restrictive and whose
.litations are
rigidly predefined. Such a health worker has a
limited impact on the health, and e, ,,I less on the
growth of his community. He spends much of his
time filling out forms.
I would not like to assert that there are necessarily
political motivations behind the shaping of either
one or the other of these two types of health
workers. Perhaps there are other reasons why
national and regional programmes so often generate
the second, more subservient type, hemmed in by
norms and forms. Nevertheless, governments in
countries with enormous inequities in land ownership, earnings and wealth must necessarily think
twice before backing, or even tolerating, rural health
or development
projects that are communitysupportive in the fullest sense.
I’m afraid I don’t have any easy answers to the
problems of politics.
Yet political factors do
influence both health and health care in ways we
can ill afford to ignore. I would strongly recommend
that those agencies, foundations and individuals that
are truly interested in the well-being of people iake
a careful look at some of the recent trends in health
care, and what is really going on.
Before closing, I would like to summarize a few of
the steps that are now being taken, or might be
taken, to implement a regional or country-wide
approach to rural (or periurban) health care which is
more genuinely community-supportive.
1. Decentralization. This means relative autonomy
at every level. Advice and coordination from the
top. Planning and self-direction from the bottom.
2. Greater self-sufficiency at the community level.
This is, of course, implicit in decentralization. The
more a community itself can carry the weight of its
own health activities, both in cost and personnel,
the less paralyzed it will be by breakdowns in supply
and communications from the parent agency.
3. Open-ended planning. For all the talk about
“primary decision making by the community”, too
often a programme’s objectives and plans have been
meticulously formulated long before the recipient
communities have been consulted. If the people’s
felt needs are truly to be taken into account,
programme plans must be open-ended and flexible.
It is essential that field workers and representatives
from the communities - not just top officials attend and actively participate in policy planning
and policy changing sessions.
4. Allowance
for variation
and growth.
If a
programme is to evolve, alternatives must be tried
and compared. Substantial arrangements for conceiving and testing new approaches, methods and
points of view shculd be built into the ongoing
programme. Also, private or non-governmental
projects should be observed and learned from, net
forced to conform or stamped out.
5. Planned obsolescence of outside input.
self-sufficiency at the community level is indeed to
be considered a goal, it is advisable that a cut-off
date for external help be set from the first. All input
of funds, materials and personnel should be
conscientiously directed towards reaching the earliest
possible date when such assistance is no longer
needed. Thus, the outsider’s or agent-of-change’s
first job, whether he/she be a medic or an agronomist,
should be to teach local persons to take his/her place
and, in so doing, make him/herself dispensible.
Outside funding, likewise, should not underwrite
ongoing activity, but should be in the form of “seed”
money or loans to help launch undertakings which
will subsequently carry their own ongoing costs.
6. Deprofessionalization
and deinstitutionalization.
We have got to get away from the idea that health
care is something to be delivered. Primarily, it
should not be delivered, but encouraged. Obviously,
there are some aspects of medicine which will
always require professional help, but these could be
far fewer than is usually supposed. Most of the
common health problems could be handled earlier
and often better by informed people in their own
homes. Health care will only become truly equitable
to the extent that there is less dependency on
professional or institutionalized
help and more
mutual self-care. This means more training, involvement and responsibility
for and by the people
themselves. It should include continuing education
for villagers which reinforce their
staying in, and serving, their communities.
7. More curative medicine. For a long time, health
care experts have been pushing for more preventive
medicine at the village level, and with good reason.
But too often, this has been used as a convenient
excuse to keep curative medicine completely - or
almost completely - in professional hands. Clearly,
measures are basic. However, the
villagers’ felt needs have consistently been for
curative measures (to heal the sick child, for
In the town of Chimbote,
end environment
a social
of women
instance). If primary health workers are to gain the
respect and confidence of their people, they must be
trained and permitted to diagnose and treat more of
the common problems, especially those when
referral without
initial treatment increases the
danger to the sick.
I should point out that when I say, “more curative
medicine”, I don’t mean “more use of medicines”.
Over-medication, by both physicians and villagers, is
already flagrant. I mean more informed use, which,
in many cases, will mean far more limited use, of
medications. But this will require a major grassroots
demystification of Western medicine which can only
happen when the people themselves learn more
about how to prevent and manage their own
illnesses. To promote such a change, village health
workers must have a solid grasp of sensible medicine
and, in turn, help reeducate their people. It
is, of course, doubtful whether such a metamorphic
awakening to sensible medicine can ever happen
outside the medical institution until there has been
some radical rethinking within it.
8. More feedback between doctors and health
workers. When health workers refer patients to a
doctor, the doctor should always provide feedback
to the health worker, explaining in full, clear detail
and simple language about the case. This can, and
should, be an important part of the health worker’s
and the doctor’s continuing education.
of practical
use and discus
how to improve
9. Earlier orientation of medical students. From the
very beginning of their training, medical students
should be involved in community health, and be
encouraged to learn from experienced village health
workers and paramedics.
10. Great appreciation and respect for villagers, their
traditions, their skills, their intelligence, and their
potentials. Villagers, and especially village health
workers, are often treated liked children or
ignoramuses by their more highly-educated trainers
and supervisors. This is a great mistake. People with
very little formal education often have their own
special wisdom, skills and powers of observation
which academicians have never acquired and
therefore fail to perceive. If this native knowledge
and skill is appreciated, and integrated into the
health care process, this will not only make it more
truly community-oriented
and viable, but will help
preserve the individual strengths and dignity of health
workers and their people. I cannot emphasize
enough how important it is that health programme
planners, instructors and supervisors be “tuned in”
to the capabilities and special strengths of the
people they work with.
11. That the directors and key personnel in a
programme be people who are human. This is the
last, most subjective and perhaps most important
point I want to make. Let me illustrate it with an
In Costa Rica, there is a regional programme of rural
health care under the auspices of the health ministry
which differs in important ways from the rural
health system in the country as a whole. It has
enthusiastic community participation and a remarkable impact on overall health. It may well have the
lowest incidence of child and maternal mortality in
rural Latin America. Its director is a paediatrician
and a poet, as well as one of the warmest and
hardest-working people I have met. The day I
accompanied him on his trip to a half-dozen village
health posts, we didn’t even stop for lunch, because
he was so eager to get to the last post before night
fell. He assumed I was just as eager. And I was; his
enthusiasm was that contagious!
I will never forget our arrival at one of the posts. It
was the day of an “under-fives” clinic. Mothers and
patients were gathered on the porch of the modest
building. As we approached, the doctor began to
introduce me, explaining that I worked with rural
health in Mexico and was the author of Donde No
Hay Doctor. Frantically, I looked this way and that
for the health worker or nurse to whom I was being
introduced. As persons began to move forward to
greet me, I suddenly realized he was introducing me
to all the people, as he would to his own family.
Obviously he cared for the villagers, respected them,
and felt on the same level with them.
This, I must confess, was a new experience for me. I
was used to being marched past the waiting lines of
patients and being introduced to the health worker,
who was instructed to show me around and answer
my questions, while the patient, whose consultation
we had interrupted, silently waited.
“This man is an exception! ” I thought to myself. In
our visits throughout
Latin America, we found
almost invariably
that the truly
programmes have at least one or two key people
who are exceptional human beings. These people
attract others like themselves. And the genuine
concern of people for people, of joy in doing a job
well, of a sense of service, and the sharing of
knowledge permeates the entire programme clear
down to the village worker and members of the
community itself.
People are what make health care work.
from this
to this
few most
majority in
accessible areas-
all the
Who are served?
Who provides the key services?
Where are training and servces provided?
health centre-
small post or
Primary concern:
sickness (of
health [of
individuals) -individuals~future
health, well-being and
of the community
Focus of action:
mother/child care
family planning
early Dx-Rx)
,Integrated Development
(health education
leadership, agriculturcommunications)
intermediate technology
I&and reform
social reform)
Geographic coverage of outreach programmes:
small, arbi’.srily
areas of great need (or beauty)
entire regions
or countries
smal I
national L
Initial objectives
Open-ended. Flexible. Consider
felt needs. Include
non-measurable (human) factors.
Closed. Pre-defined before community
is consulted. Designed for hard-data
evaluation only.
Size of programme
Small, or if large, effectively
decentralized so that sub-programmes
in each area have the authority to
run their own affairs, make major
decisions, and adjust to local needs.
Large. Ofton of state or national
dimension. Top-heavy with bureaucracy,
red tape, filling out forms. Superstructure
overpowers infrastructure. Frequent
breakdown in communication.
Planning, priorities,
and decision making
Strong community participation.
Outside agents-of-change inspire,
advise, demonstrate, but do not
make unilateral decisions.
community participation
is great. In fact, activities and decisions
are dominated or manipulated extensively
by outsiders, often expatriate “consultants”.
Financing and supplies
Largely from the community.
Self-help is encouraged. Outside
input is minimal or on the basis of
“seed funds”, matching funds, or loans.
Agricultural extension and other
activities which lead to tinancial selfsufficiency are promoted. Low-cost
sources of medicine are arranged.
Many giveaways and handouts: free food
supplements, free medicines, villagers
paid for working on “community
Village health worker (VHW) salaried from
outside. Indefinite dependency on
external sources.
Way in which community
is achieved
With time, patience, and genuine
concern. Agent-of-change lives with
the people at their level, gets to know
them, and establishes close
relationships, mutual confidence and
With money and giveaways. Agents-of
change visit briefly and intermittently,
and later on discover that, in spite of
their idealistic plans, they have to
“buy” community participation.
Care is taken not to start with free
services or giveaways that cannot
be continued.
Many programmes start with free
medicines and handouts to “get off
to a good start”, and later begin to
charge. This causes great resentment
on the part of the people.
Underemphasized. Data-gathering
kept simple and minimal, collected
by members of the community.
Includes questions about the people’s
felt needs and concerns.
Over-emphasized. Data gathered by
outsiders. Members of the community
may resent the inquisition, or feel
they are guinea pigs or “statistics”.
Simple scheme for self-evaluation
of workers and programme at all levels.
Evaluation includes subjective human
factors as well as “hard data”.
Evaluation based mainly on
“hard data” in reference to initial
Data and evaluation
Experience and
background of outside
Much practical field experience.
Often not highly “qualified”
Much desk and conference room
experience. Often highly “qualified”
Income, standard of
living, and character of
outside agents-of-change.
(MDs, nurses, social
workers, consultants, etc.)
Modest. Often volunteers who live
and dress simply, at the level OT the
people. Obviously they work through
dedication, and inspire village workers
to do likewise.
Often high, at least in comparison
with the villagers and VHW (who,
observing this, often finds ways to
“pad” his income, and may become
corrupt). The health professionals have
often been drafted into “social service”
and are resentful.
Sharing of knowledge
and skills
At each level, from doctor to VHW to
mother, a person’s first responsibility
is to teach: to share as much of his/her
knowledge as possible with those who
know less and want to learn more.
At each level of the preordained medical
hierarchy (health team), a body of
specific knowledge is jealously guarded
and is considered dangerous for those
at “lower” levels.
Regard for the people’s
and traditional
folk healing, use of
foi k healers
Respect for local tradition. Attempt
to integrate traditional and Western
healing. Folk healers incorporated
into the programme.
Much talk of integrating traditional
Western healing, but little attempt.
of respect for local tradition. Folk
healers not used or respected.
Scope of clinical
activities (Dx, Rx)
parformed by VHW
Determined realistically, in response
to community needs, distance from
health centre, etc.
Delimited by outsiders who reduce the
curative role of the VHW to a bare
minimum, and permit his/her use of only
a small number of “harmless” (and
often useless) medicines.
Selection of VHW
and health committee
VHW is from and is chosen by community.
Care is taken that the entire community
is not only consulted, but is informed
sufficiently so as to select wisely.
Educational prerequisites are flexible.
VHW ostensibly chosen by the community.
In fact, often chosen by a village power
group, preacher, or outsider. Often the
primary health worker is an outsider.
Educational prerequisites fixed
and often unrealistically
Training of VHW
Includes the scientific approach
to problem solving. Initiative and
thinking are encouraged.
VHW taught to mechanically follow
inflexible, restrictive “norms” and
instructions. Encouraged not to think
and not to question the “system”.
Does the programme
include conscientization
(consciousness raising)
with respect to human
rights, land and social
Yes (if it dares).
Issues of social inequities, and
especially land reform, are often
avoided or glossed over.
Simple and informative in language,
illustrations, and content. Geared to
the user’s interest. Clear index and
vocabulary included. All common
problems covered. Folk beliefs and
common use and misuse of medicines
discussed. Abundant illustrations
incorporated into the text. The same
time and care was taken in preparing
illustrations and layout as villagers take
in their artwork and handicraft.
unattractive. Pure
instruction. No index or vocabulary.
Language either unnecessarily complex
or childish, or both. Illustrations are few,
inappropriate (cartoons), or carelfssly
done. Not integrated with the text. Useful
information is very limited, and some of
it inaccurate. Many common problems
not dealt with. May use misleading and/or
incomprehensive flow charts.
Manual contains a balance of
and promotive
Manual often strong on preventive and
weak on curative information; overloaded
with how to fill out endless forms.
Limits defining what
a VHW can do
Intrinsic. Determined by the demonstrable
knowledge and skills of each VHW, and
modified to allow for new knowledge
and skill which is continually fostered and
Extrinsic. Rigidly and immutably delimited
by outside authorities. Often these imposed
limits fall far short of the VHW’s interest
and potential. Little opportunity
Supportive. Dependable. Includes further
training. Supervisor stays in the
background and never “takes over”.
Reinforces community’s confidence
in its local workers.
Restrictive, nit-picking, authoritarian,
or paternalistic. Often undependable. If
supervisor is a doctor or nurse he/she
often “takes over”, sees patients, and
lowers community’s confidence in its
local worker.
Encouragement of
self-learning outside
of norms
Yes. VHWs are provided with
information and books to increase
knowledge on their own.
No. VHWs are not permitted
books providing information
their “norms”.
Feedback on referred
When patients are referred by the VHW
or auxiliary, the MD or other staff at the
referral centre gives ample feedback to
further the health worker’s training.
Doctor at the referral centre gives no
feedback other than instructions for
injecting a medicine he/she has
prescn bed.
Flow of supplies
Profit from medicines
(in programmes that
VHW sells medicine at cost which is
posted in public. (He/she may charge a
small fee for services rendered). Use of
medicines is kept at a minimum.
VHW makes a modest (or not so modest)
profit on sale of medicines. This may be
his/her only income for services, inviting ~
gross over-prescribing of medicines.
Evolution towards
greater community
As VHWs and community members gain
experience and receive additional
training, they move into roles initially
filled by outsiders -training,
management, conducting of Under-fives’
clinics, etc. More and more of the skill
pyramid is progressively filled by members
of the community.
Little allowance is made for growth of
individual members of the community to
fill more and more responsible positions
(unless they graduate to jobs outside the
Outsiders perpetually perform
activities that villagers could learn.
Manual or guidebook
for VHW
to have
Openness to growth and
change in programme
If outside support
fails or is discontinued...
New approaches and possible improvements are sought and encouraged.
Allowance is made for trying out alternatives in a part of the programme area,
with the prospects of wider application
if it works.
Health worker continues to learn and to
grow. Takes pride in the work. Has
initiative. Serves the community’s feli
needs. Shows villagers what one of their
own can learn and do, stimulating
initiative and responsibility in others.
Entire programme is standardized with little
allowance for growth or trial of ways for
possible doing things better. Hence, there
is no built-in way to evolve towards better
meeting the community’s needs. It is static.
Health worker plods along obediently, or
quits. He/she fulfills few of the community’:
felt needs. Is subservient and perhaps
mercenary. Reinforces the role of
dependency and unquestioning servility.
Community becomes more selfsufficient and self-confident.
Human dignity
Human dignity fades. Traditions are lost.
Values and responsibility degenerate.
and responsibilit:
becomes more dependent on
outside charity and control.
Health programme
Health programme continues because
it has become the community’s.
Social reform: health and equal
for all.
“Don’t rock the boat”. Put a patch on
the underlying social problems - don’t
resolve them!
Often small, private, religious, or
volunteer groups. Sometimes sponsored
by foreign non-governmental
Often large regional or national prograrnmes
cosponsored by foreign national or multinational corporate or governmental
1. E.F. Schumacher.
New York, 1973.
2. Milton Silverman. The Drugging of the Americas,
versity of California Press, Berkeley, Calif., 1976.
Is Beautiful.
& Row,
3. The Haslemere Group. Who Needs rhe Drug Companies
Third World Publications, Birmingham, England,
A major concern of health planners, be they
government officials,
medical doctors or field
workers, is how to implement a community-based
health programme. There are communities which,
having very little health care, can, from the
beginning, decide what services they need, what
people can deliver them and what contributions the
community will make. However, in the majority of
cases, health institutions and medical professionals
are already present in the community. The problem
is how to restructure and reorient the existing
programmes in order to realize community participation rather than simply community contributions.
questions which are basic to any planner who must
deal with the practicalities of programme planning.
The programme has two features which have
contributed to creating a community involvement in
health care. The first is a carefully planned social
preparation of the community so that both the
health staff and community people can develop
together the strategy and process of community
participation. The second is use of a community
development rather than health delivery approach
which has meant the programme now includes such
activities as credit u.nions, cooperatives and sanitary
The final selection in this volume is a description of
how planners can develop a community-based
programme, using existing health resources and
medical manpower. It appeared previously in two
CMC publications: CONTACT No. 43 (February
1978) and CONTACT Special Series No. 1 (April
1979). Written by Mary Johnston, who draws on
her ten years’ experience in developing a Dana 8ehat
(health insurance) programme in central Java,
Indonesia, it explains in simple, concise, language
the steps that can be taken. It also explicitly raises
Neither the author nor the editor claim that this is
the model for developing community-based health
programmes. It is the experience of one programme
in a specific context. It does, however, present an
approach which incorporates many of the points
which have been raised by other contributors to this
volume. By including it in this book, the reader is
provided with one concrete example which might
stimulate ideas for the creation of other programmes.
Mary Johnston
A. Promotion With the Government
e How can the doctor avoid friction with senior
officials if the programme is eventually more
successful than their programme?
6. Consolidation
+ Government support must be gained in the initial
stages of a programme.
of the Health Staff
C. Approach to the Community
D. Social Preparation of the Community
1. To gain official
E. Field Preparation
2. To recruit
technical advice, facilities and funds.
I. Selection of Initial Project Area
I I. Collection of Data about the Community
I II. Determination of Problems to be Tackled
and Setting Priorities
IV. Planning Programme Implementation
F. Implementation
of the ProgrLmme
3. To gain support from other disciplines at the
same, or higher, levels in order to develop a
comprehensive programme.
4. To integrate the programme into the government
programme and prevep.2. overlapping and competition.
G. Monitoring
H. Assessment
Expansion of Established Programme
K. Extension of Programme to other Communities
L. Promotion and . Training in New Area and
Repeat of WholeProcess in New Community.
How can a doctor gain acceptance from peers and
supervisors for ideas of experimentation
with a
health programme?
How can such a programme be integrated into the
overall government programme?
Discussion with senior government officials until
some consensus is reached on concept of community health, and the idea to set up a community
health programme in a specific locality is approved.
Needed for Successful Action
1. Current government health policy, including
opinions and statements from senior officials and
international sources, on community health.
2. Overall plan of implementation should include
ideas on:
- organization/framework
which programme will be developed,
- financial aspects,
- advantages over current system, eg., wider
coverage, more economical
use of staff,
cheaper. (In discussing advantages, factors of
special interest and importance to the government officials should be emphasized).
3. Criteria for the selection of locality
should include the following:
Tor trial
- the community
to be served should be
manageable, viable and, preferably, an established administrative unit such as a village or
- the unit should have economic potential;
- it should have strong, active, honest leadership;
- it should be strategically placed to enable
expansion to other areas.
How will staff who have worked for years in a
curative service accept a programme with a new
How can a doctor secure the support of the rest
of the health team for a new programme? No
doctor can implement
a community
programme alone.
+ It is important
health service.
to consolidate
the staff
of the
1. To prepare the health staff for a programme
oriented to the community.
2. To provide the staff
community work.
skills required
ante at health service, etc.;
contact with community health workers;
visits to successful community
Training should provide skills in:
- approaching the community,
- communicating with the community,
- working together with the community,
- planning,
- maintaining
and developing a programme, and
- simple administrative skills.
iii. Training methods could include:
- discussions,
- exposure to situations followed
reflection on the situation,
- problem solving, and
- role playing, etc.
How can a health programme
community-based programme?
How can a doctor help the community
its own health problems?
to tackle
-+ it is important
that the community
be approached in the very early stages of development
of the programme. Close cooperation between the
health service and the community
is essential.
3. To form a cohesive team
To gain the support and the direct, active
participation of the community in developing the
Retraining the staff of the health service, including,
if necessary, its reorganization.
Needed for Successful Action
1. On forming an effective team.
A team which understands and accepts the new
approach and feels confident in implementing
it is needed. The team may consist of:
- a doctor, or other team leader,
- paramedics, and nursing staff,
- social worker, and
- agriculturalist
(or other technical worker,
depending on local community needs).
If it is not possible to increase staff, current
staff can perhaps be equipped with extra skills.
2. On training content and methods.
i. Training should achieve changes in attitudes,
- statements proving government interest
in, and support of, new orientation;
- proof of need for new orientation, eg.,
clinic statistics indicating limitations of
existing service, reasons for non-attend110
Health worker approaches the community leader
Health worker is approached by the community
leader. (This is only likely to happen in a
where a successful programme has
already been established in the vicinity.)
Needed for Successful Action
1. For the identification of a sympathetic
nity leader, criteria should include:
- interest in health
- active interest in community welfare,
- innovative ideas, and
- influence in community.
2. Method of Approach.
Discussions should focus on:
- particular issues, events occurring in community (death, epidemic, special day);
- statistics from local clinic
(high disease
incidence, disease patterns); and
- examples of programmes in other areas.
1. Official approval of local leader is prerequisite.
If a direct approach to formal leaders is not
possible, or unsuccessful, informal leaders, eg.,
teachers, religious leaders, may be approached.
When they are convinced about the new ideas,
they can be encouraged to influence the formal
A government superior (es., a district head) may
be the needed contact person in other cases.
2. It is unusual for the initiative in setting up a
health programme to be taken by the community.
But where this occurs and the existing health
workers are unresponsive to approaches from
village leader, the help of a more senior official,
eg., senior doctor, senior government official,
could be requested to convince the health worker,
through discussions and visits to successful
How can the whole community (as opposed to
leaders only) participate in programme development?
How can a health worker make contact with
members of the community? What channels wn
be used?
How can the health worker avoid the danger of
arousing a feeling within the community that
their cooperation is desired merely to further the
ambitions of the health worker?
+ Social preparation
of the community
the success of a programme.
is crucial
1. To develop community understanding of the basic
aims of the programme.
2. To encourage the community to reach a decXon
to implement a programme based on its particular
3. To mobilize local resources.
1. Informal individual and group discussions about
community problems and needs and the proposed
health programme, held between
health worker and leaders in the community.
2. Community
leaders, assisted by the health
worker, then introduce the idea of the community health programme, informally and through
community groups and meetings, to community
3. Discussions should be held until a decision is
reached by community leaders and community
members (if possible) to implement the community health programrne.
needed for successful action
1. Influential community leaders include:
- formal leaders, eg., government, traditional,
religious; and
- informal
leaders, eg., religious, educated,
wealthy, political.
The support of both formal and informal leaders
is important.
2. Existing
- ongoing activities,
- membership representing the whole community,
- sound leadership, and
- a flexible programme.
Approach should be made to such organizations
as the community
health programme could
possibly be inserted as the L ogramme of one of
these organizatio;ls.
3. Research to identify community problems and
needs may include investigations on:
Health: general observation, especially of deficiencies,
in the
under-fives’ group;
noting major illnesses as recalled by members
of the community (and indicative of the high
incidence of certain diseases);
collecting data on number and causes of deaths
and incidence of epidemics (or threat of);
Education :
asking local teachers about their problems;
comparing number of school-age children with
number of school attenders;
checking drop-out figures and reasons;
checking distance from nearest market, school
and other important facilities;
checking means of contact with, and transport
to, secondary health care facilities;
comparing yields with expected average yields
of area;
asking farmers for their opinions of problems
and needs;
observing gerleral conditions in the field.
4. Customary ways in which the community
When obtaining information about major needs
and concerns, also ask about ways in which the
has tried to meet these needs.
Possibly the customary
ways of solving
problems can be developed and incorporated
into the new programme.
Eg.,: If a community collects funds to cover
funeral expenses, this could be developed into a
simple insurance scheme In which subscriptions
are collected to provide health care for the
+ Joint preparation
of the field, including selection
of a limited
area for trial, collection
of data,
of priorities,
and planning
5. Methods by which the community
a. Determine which groups/group
leaders are
most influential in the community as they are
the best channels through which to gain
community support.
b. Determine which is the officially recognized
which the final decision for acceptance of the
programme should be made.
How can a community
be convinced that a
programme is feasible and of benefit to them?
How can ideas be tried out without
jeopardizing the w-hole programme?
their failure
How can programme implementors
dence from experience?
gain confi-
To select a restricted area, with high probability
success, for trial.
leaders and health worker
decision on locality for trial programme.
reach a
needed for successful action
1. Nature of appropriate locality.
The site most conducive to successful implementation would be:
- an existing community, preferably a small
administrative unit, eg., subhamlet or village;
- manageable in size;
- an economically viable community; and
- one with good leadership.
(In subsequent development of the programme
in other areas, weaknesses can be overcome by
many means, e.g., an economically weak unit
could be combined with a vigorous and thriving
Important factors
1. The health worker must have an open, friendly
attitude, indicating willingness to learn about the
community from the people.
2. The introduction
of the proposed programme
should always be through discussions on major
concerns of the community. Through discussions,
assesswhat these are and start there.
A volunter health promoter programme
could be suggested as an answer to the problem of
long distances from the health service.
4. NR At ‘this
stage, the community
programme is accepted in principle only. Details
of the programme have not yet been worked out.
c. Determine the type and frequency of group
meetings. If the decision is reached in a formal
meeting attended by a large moportion of
leaders and community memtiers, it will have
stronger backing and suppot%.
d. Determine whether decision making is:
a decision by the recognized leader,
0 majority vote, or
discussion culminating in unanimous decision. Whichever decision-making method is
used, it is important
that as many
community members and leaders as possible
understand and agree with programme.
3. In a community where health is not a major
eg., a poor, isolated community,
implementation of a health programme may have
to be postponed until other more pressing needs
felt by the community are met
Eg., An agricultural programme which raises crop
yields may provide the community
with the
economic means enabling them to use the
proposed health service.
Non-formal education may increase awareness
and understanding of the advantages of healthier
I ivjh g.
2. Nature of local leadership.
The leadership of the trial unit should be:
- authoritative,
- honest,
- actively interested in the welfare of the
community, and
- supported by the community.
(In subsequent development of the programme,
weak leadership can be overcome by many
means, eg., by working through strong informal
leaders with formal leader as figurehead.)
How can the community and health worker learn
more about local conditions?
How can a programme be based on real and felt
needs of a community?
1. To provide baseline data.
2. To enable local leaders to become more aware of
conditions in their community.
3. To increase the awareness of the community
problems facing them.
1. Prepare simple questionnaire suited to local needs
and adapted to the skills of the interviewers.
2. Inform leaders of the purpose of the questionnaire and reason for collecting data.
3. Selection of interviewers,
4. Training of interviewers.
5. Data collection.
6. Tabulation and analyses of data.
needed for mxessful
1. Community to be covered.
It is important to collect data from the whole
if conditions
are favourable.
However, if community to be covered is too
large, sampling methods should be used. These
methods can be studied in a handbook on
2. Content of survey.
The data should cover both the community in
general and individual families.
items such as number of
On community,
families, average family size, public facilities
and vital statistics, should be covered. On
families, information
on factors such as
number in family, ages, education, occupations, income, health status, environment,
mother and child care, agriculture and social
customs should be included.
3. Method of composing questionnaire.
Questionnaire should be short and seek only
which can be used either
directly for programme planning, or as an
indicator of success for the monitoring of
the programme.
o Ensure that the questions have one meaning
only and will bring the answers required.
Ensure that questions are not suggestive of a
particular answer.
Ensure that answers are given in a way which
is easily tabulated, eg., by using simple
indicators, such as + = good; f 4 fair; - =
4. Selection of interviewers.
If possible, community members should do the
Choose community
- ability
to approach fellow
- ability to ask questions honestly and record
answers accurately, and
- interest in programme and time to spare.
If volunteer health workers have been formed
before collection of data, this task should be
given to them to increase their awareness of
community conditions, and to provide a basis
for them to plan their programme.
5. Content and method of training interviewers.
Training should include:
- reasons for asking questions in questionnaire,
- guiaance on how to explain need for data
collection to community members,
- guidelines for interviewing
techniques, including information on how to:
create an open, friendly atmosphere,
ask open and closed questions,
prevent bias in answers, and
cross-check answers, and
- instruction on how to fill in questionnaire.
Training methods could include: discussion, role
by discussion of
play, trial run followed
6. Method of collecting data.
a. Coverage: The capacity of one intervie&er in a
rural area where homes are widely separated is,
at a rough estimate, 10 families a week;
b. Timing: Home visits should be geared to times
when community members are at home;
c. Supervision:
Supervision of interviewers is
important to maintain their enthusiasm and
increase validity
of data. Such supervision
should include spot checks of difficult
questions, close recording of time taken in
interview, number of interviews conducted,
etc. Each interviewer should keep his/her own
records. Daily discussion of results is helpful
for increasing skills.
7. Method of tabulation.
Tabulation can be done by community members
with guidance from health workers.
Response frequency for each question should be
counted and tabulated.
Respondents can be divided into groups based on
employment, size of family, education of parents,
or other relevant factors.
8. Method of analysis
Each item in the tabulation
can be evaluated
according to simple criteria, such as: good/bad,
Those items assessed as bad, insufficient and
unsatisfactory are raw material on which to base
plans for programme.
2. Criteria for determining
1. Data collection is important, but if problems arise
(es., suspicious community
leader, suspicious
community members, inappropriate timing), data
can be collected in stages as the need arises for
specific programmes (eg., under-fives’ programme,
environmental improvement programmes).
The health worker together with the community can make a simple analysis of results by
evaluating each problem according to the above
criteria using a scale of O-3. The scores are then
multiplied to gain a final score. Priorities are
determined, the problem with the highest score
gaining first priority.
As far as possible, the key members of the
community should be involved in determining
priorities. Their involvement ’ in all decision
making will increase the validity
of the
decisions and increase their commitment to the
programme. Both short- and long-term priorities should be determined to provide the vision
of a continually
developing, comprehensive
2. Data collection could also be postponed until
volunteer health promoters have been trained.
Advantages of using volunteer health promotors:
- they are known by the community,
- have an intimate knowledge of the community,
- can gain increased awareness of problems, and
- can obtain data for planning their programmes.
NB: It is especially important to safeguard bias if
health promoters or other local people are used.
How can a community set priorities in the face of
a large number of problems?
How does one select the “right”
3. Criteria for selecting initial activity:
- low cost,
- limited to small, feasible size,
- ability to produce results within * 6 months.
initial activity?
Using these criteria, plans should be realistic
and within the scope of the community. Hence
success will be maximized, resulting in a
relationship of trust and confidence between
the community and the health worker.
1. To initiate a dynamic programme.
2. To select a small-scale, low-cost activity
will produce quick results.
3. To provide stimulation for continuing
ment of the programme.
It is important also that the initial activity
should stimulate further activities, leading to a
more comprehensive programme, eg., that a
nutrition programme might stimulate improvements in agricultural techniques, or a savings
programme stimulate small productive activities.
1. Presentation of survey results to community
leaders and community members (if possible).
2. Determination
of priorities and of initial activity.
needed for successful action
1. Reporting survey results.
Survey results should be reported back to the
community in a form understandable to them.
A descriptive, non-technical form highlighting
problems and also potentials may be most
effective. If possible, the report should be
made both orally and in writing. The oral
to community
leaders, both
formal and informal, provides a good opportunity for discussion of major community
problems, both those in the report and those
felt by the community.
to be con-
Four simple criteria can be considered:
- What is the incidence of the problem in the
- How serious is it as a health problem?
(Opinion of health worker)
- What importance does the community place
on the problem?
- How difficult is it to overcome? (Management considerations).
Important factors
As experience is an invaluable teacher, how can
members of the community
acquire skills in
planning and management though experience?
1. To make plans acceptable to both the community
and health service.
2. To involve all parties in planning and implementation.
3. To increase community
manpower use, etc.
(This may take several meetings.)
1. Meeting of community
leaders, community
members (if possible) and health worker to make
plans for implementation,
on invitation
community leaders.
2. Setting up committee and administration,
ing a division of responsibilities.
1. Simple methods of planning and management.
2. Methods of conducting a meeting so that those
present contribute and plans stem from joint
Preferably, these meetings should be called and
led by the committee. If there is a division of
responsibilities amongst the members, all will
have a meaningful contribution to make to the
needed for successful action
1. Existing organizations in the community.
-If possible, the programme should be set up
through existing organizations.
If necessary, these could be reactivated, given
new functions, etc.
Only when this proves impossible should a new
be created to carry out the
2. Type of framework for programme.
Examples of possible frameworks within which
to set up a programme are as follows:
a. A simple health insurance scheme can
provide a framework
for developing a
gramme, eg., environmental improvements,
credit union, volunteer health promotors,
under-fives’ weighing, etc., can all be built
into the framework as community awareness
increases and needs arise.
b. A volunteer health promotors’ programme
could also provide the framework for similar
activities, as well as improved use of home
gardens, under-fives’ nutrition programme,
health posts, etc.
needed for successful action
3. Resources available within the community and
those from without the community (if required).
These include: materials, equipment, funds,
skills, technical knowledge and manpower.
Data collected in initial stages should provide
details on resources within the community.
Important factors
1. Plans should only be carried out after the
community is prepared, ie., after social preparation and field preparation are completed.
2. The community leaders and members should be
responsible for making the plans, not the health
3. The role of the health worker is:
- To assist the committee
in considering
problems which may arise during implementation,
- to provide technical information, and
- to “prod” the committee (if needed), eg., if
chairman “forgets”
to call a
o How can the community best be made aware of
its own strengths and resources, and encouraged
to use those resources?
1. To carry out plans efficiently with active support
and participation of the community.
2. To mobilize local potential and resources.
3. To develop management and other skills in the
Community leaders, committee and health worker
meet to discuss the implementation
of plans,
steps, timetable,
of tasks,
What should be done if action planned together is
not implemented?
o How can the community
progress of a programme?
+ Ongoing monitoring
of the progress of activities
1. To <follow the progress of implementation
2. To study the relationship
and impact.
3. To stimulate
between input, output
the community
4. To revise methods, if necessary.
1. During
progress is monitored
by trained
2. The community, community leaders and health
worker meet periodically to discuss the results of
the monitoring.
Criteria for measuring progress could include:
- change of disease pattern,
- infant mortality rate,
- incidence of illness in community,
- improvements in environment,
- increased community participation in health
- community’s use of service (accessibility and
acceptability), and
- effectiveness of service (cost and benefit).
Data on results achieved through programme is
compared with baseline data collected in initial
stage of programme.
1. Simple methods of monitoring.
It is essential to work out a simple recording
system which is meaningful to the community,
and can be kept by community
Community members should be trained in the
use of the system.
ways to provide
of infor-
The opportunity
must be provided for the
to receive regular reports of
progress, eg., at community
meetings, at
regular committee meetings, through poster
Informal contacts with community
should also be used for feedback of information about the programme. Both formal and
informal contacts provide an opportunity for
the community
to give feedback to the
committee on reasons for success or failure to
Needed for Successful Action
1. Simple method of assessment.
lr,fsrr. iation needed for successful action
2. Effective
based on results of assessment are
Important factors
The assessment must help the community
understand the results of their programme.
1. Community leaders (and if possible community
members) should be involved in making the
assessment. (Eg., the monitoring records could
be used.)
2. The assessment must be prepared and presented in a form understood by the community.
3. The assessment must be reported back to the
community members.
What steps should be taken if a programme
becomes static because the community
interest and no new ideas arise?
How can the community
assess the results of its
+ Assessment
of end results
of activities
for programme development.
NOTE: This step is only necessary if assessment
reveals that 3n activity
is not meeting
programme objectives, or programme. objectives are not meeting community needs.
+ It is important to maintain
which meets the changing
a dynamic programme
needs of the commu-
1. To assess whether results of activities within the
programme are satisfactory and meeting the aims
of the programme.
2. To stimulate the development of other activities.
2. To reorganize the programme to meet the needs
of the community more closely.
1. Community
leaders, committee
and health
workers meet for discussion of results of activity,
(In a long-term programme, these meetings are
held periodically.)
2. Community
meetings are held by community
leaders where results of assessment by committee
are discussed, and ideas on expansion of the
1. To increase the effectiveness and efficiency of the
In a meeting of the community leaders, committee
and health worker, decisions are made on the need
for revision and methods of revision.
needed for successful action
1. Aspects needing revision.
These will be evident from the results of the
monitoring and assessment.
2. Alternative
Using important events to stimulate
action, eg., Independence Day preparations could include work on environmental improvements.
Using dramatic events, eg., an outbreak
of an epidemic or a death, to increase
action to
awareness and stimulate
prevent a further occurrence of the same
activities which are more appropriate.
Important factors
A community is never static; community needs are
changing. Therefore a flexible programme is required, and programme implementors
must be openly willing to change and revise
programme as needed. A programme should be
dynamic, never static.
How can the causes of problems be attacked?
For example, the community not only collects
blood samples to detect malaria infection, but
also works towards the eradication of mosquitoes.
How can the community
healthier living?
Before implementing any new activity, it is essential
to repeat the steps of social preparation and field
1. To improve the quality of the programme,
through expanding the number and type of
2. To meet health needs of the community more
adequately through a comprehensive programme.
How can other communities benefit from the
gained earlier by an established
community health programme?
Who is responsible for the development of a
community health programme in other communities?
Who can find time to work with other
communities, given the limited resources available?
reach the goal of
To motivate leaders in other communities to adopt a
community health programme;
In periodic meetings, possibly at the same time as
assessment, community
leaders, committee and
health worker, propose, select and plan further
(This meeting is preferably called by community
Exposure of key people from other communities
to the original programme.
needed for successful action
1. Methods of motivating community leaders and
members to propose new activities may include:
- visits to more advanced programmes;
- development of a new activity in a limited
by encouragement of
satisfied community members to stimulate
other localities to follow their example; and
- competitions.
2. Ways of encouraging community members to take
more initiative should be based on increasing their
awareness about their community
and its
This can be achieved by:
i. Training selected community members
as volunteer health promotors so that
they will have a deeper and more critical
understanding of the causes of health
problems and ways to overcome them.
needed for successful action
1. Media for promoting contact with other communities could include:
i. Observation visits to original programme.
ii. Contact between leaders of a community
which has not yet begun a programme
with experienced leaders of the community health programme.
iii. Government channels, eg., introduction
of programme at meeting of formal
iv. Mass media.
v. Audio-visual aids, eg., filmstrip describing community health programmes.
vi. Public
meetings, eg., seminars, work-
vii. Printed brochures,
manuals and other
2. Early interest and motivation
by the following:
can be reinforced
- government instruction which provides backing for the programme. To avoid negative
effects of instruction
from above, the
community should be prepared to receive it;
- provision of more detailed oral and written
information, eg., full description of how to
implement programme.
Important factors
1. This step may be carried out only when the initial
programme is firmly established, i.e., when:
- the community feels they are profiting from
the programme,
- community leaders and members are able to
relate their experiences, and
- intensive supervision is no longer required.
2. It is preferable that communities take the
initiative in beginning the process of developing a
programme in their area.
How can limited resources best be used’to equip
others to develop a satisfactory programme?
How can the initiators of a new programme learn
from the successes and failures?
+ A newly developing progr?.mme
the experience gained through
can benefit
an existing
1. To establish the programme in the new area on a
firm foundation.
2. To provide a basic understanding
of the
philosophy and broad content of the programme.
3. To share information
programme in a new area.
4. To encourage the development of a flexible,
dynamic programme related to local conditions
and needs in the new area.
1. Community leaders and/or health workers in new
area commence promotion with the government
and approaches to the community.
2. Training of key people from new area, including
community leaders and health workers.
needed for successful action
1. On identity
of key formal and informal
2. Appropriate
training methods and content.
Trainers should be people with experience in
existing programme, including health workers,
community leaders, volunteer health promoters. The curriculum and organization of the
training should be determined by trainers and
trainees together, based on needs of trainees.
Training material should include basic philosophy and broad outline of programme only, as
it is important
that the details of the
programme should be determined by the local
community, according to local conditions.
Important factors
1. It is important to be aware of the disadvantages
which could arise from using a programme as a
training field, and attempt to forestall them.
Possible disadvantages could be: oversaturation of
the field; jealousy from other areas which are not
used for training; or development of excessive
pride and self-satisfaction resulting in an inability
to receive any new ideas from outside.
2. The training is followed by social preparation,
field preparation and all the subsequent steps
outlined above.
3. Continuous contact between those involved In the
existing programme with those developing the
new programme is valuable to both parties.
readings in this volume review a wide range of
Gences of community participation in development and health. Rather than summarize the major
points, it is perhaps more useful to look at these
ideas as a basis to formulate some guidelines for
developing successful community-based health programmes. These guidelines can take the form of
propositions in which community participation is
taken to be a strategy and a process, and health is
defined as a human condition rather than a delivery
of a service.
A major determinant of the growth of a programme
is the definition which those who have control over
resources give to the programmes’s objectives. The
major resource holder is the national government.
When, in countries like Tanzania and China, the
government allocates those resources and supports
community participation, programme objectives can
be realized in a relatively short time. In comparison,
several of the essays have shown the difficulty of
developing programmes in countries where governments either show little interest or feel threatened
by a community which takes too much initiative. A
health programme which is
supported by official policy is of a very different
character than one which is not.
In addition to government there are, in any
certain groups that are in a better
position than others to control resources. To
develop a community health programme in which all
sectors of the community can make demands and
get some type of access to those resources is
basically a political procedure which takes a great
deal of time and effort. Much of this time and effort
will be spent in ensuring that those who most need
resources can have access and that the community
leadership takes a responsible view of distribution.
To meet this goal, those non-community
who are working with community
people to
establish programmes must help the community to
develop a careful understanding of vested interests
and social structures in order that responsible
leadership develops. A community-based
programme recognizes the political context and
works with a clear understanding of that context
and with the objective of evolving a structure which
responds to the needs and priorities of the total
The very nature of community participation in the
decision-making process, which has heretofore been
reserved for those who are powerful
professional, means struggle for control will ensue.
The conflicts centre around how to enpower people
who, traditionally, are passive recipients of policy.
This act implies that those who now control must
give up resources to provide for a change. While
these resources may range from information
professionals on how to treat diseases to finances for
developing health services, people who now have
these resources do not often give them up willingly.
There are many examples where gains have been
made through direct confrontation
between two
opposing sides. The classical example of confrontation policy is, of course, social revolution which is
not very practical in most communities
at this moment
in history.
community has inherent structures and traditions
that may support or deny confrontation as the best
means to develop community participation. While it
may be possible to define situations which, in any
given community, may be responsive to confrontation, it must be remembered that different
communities have different solutions to different
problems at different times. A community-based
health programme develops a careful analysis of
problems in the context of the sociopolitical and
economic structures and potentials and uses a range
of methods to cope with inherent struggles for
The value of the approach in which professionals go
into a community and ask them what they want has
been under attack by many with field experience in
community work. For one reason, in a community,
most people will respond to a question of “what do
you want? ” with an answer which either reflects
their view of what you want to hear or what they
think you will give them. For another reason, the
has often provoked surveys of the
community upon which experts act to give the
community what they think they need. The basic
question in a community participation programme is
how the members of a given community, with all
their problems, traditions and diversities, can te
motivated to act together to improve thcit
communal environment. The answer to this que??;on
does not depend on surveys but on dialogue.
In considering the dialogue process, the most
important principle is for professionals to rot. only
involve, but also take seriously, the contribution of
various community
members. The often-used
diagnosis” in which medical professionals go to the community to discover the various,
facets of social, economic and political life loses its
meaning if the professionals, after analyzing their
data, return to the community and tell tFle people
what they, as professionals, think is good for the
The objective of community/professional interaction, as the readings have pointed out,
should be an interchange of views about how to
solve a mutual, agreed-upon, problem. Failing to do
this, the programme evolves in a traditional context
in which- the professionals give advice, give services
and give everything but power of decisions and,
thus, the potential of realizing human development
to the community.
A community-based
programme recognizes that the most important “felt
need” of the community
is to control
programmes that affect them.
One of the major challenges that faces communitybased health programmes today is the attempt to
replicate on a large scale some of the more
successful small pilot programmes. The problem of
replication arises, in no small part, because the pilot
schemes have freedom and resources to experiment
and to Gorrect errors, but have neither the means
nor machinery to implement their programme on a
large scale. When programmes are implemented for
either by government or a
large populations,
voluntary agency, they lose their flexibility
emerge from a uniform
mould. Once these
programmes become institutionalized,
they demand
a type of accountability
which tends to be both
hierarchical and inflexible. Recognizing this problem,
one workable solution is decentralization of decision
making which allows local communities to deal with
local problems. However, the system of decentralization must provide channels for accountability, error
correction and information sharing. A communitybased health programme grows within a context of
large-scale, preferably national-government support
wi-th a view towards replicability
and with the
authority to develop in a way which responds to its
particular circumstances. This proposition is one of
the most difficult to realize.
In a community-based health programme where the
goal is development of human potential, and
improvement in health status is a major byproduct,
there is experience to suggest that a direct attack on
health problems by delivering health services does
not necessarily achieve the goal. While it is true that
health activities do lend themselves to involvement
of ordinary people and often do produce dramatic
results in a short time, it is also true that it is a field
overburdened with professionalism. The efforts to
overcome professional resistence in both the local
and national scene may be better used directly to
attack poverty by introducing income-generating
activities. Some communities have agreed to build
or find ways of
an agriculture
implementing a cooparative credit system but have
rejected a community
health worker scheme. It
must be reeognized that improved health status is
more a result of improved nutrition
and better
housing conditions created by increased income
than it is of provision of health services, A
community-based health programme considers improved health as one means of improving the
life-style and sense of ability to
control its destiny; it, therefore, sees health services
as a possible, but not the only, entry point for
A professor of mine iii England once said that the
most impor,tant task any professional can do in the
developing world is to teach what he/she knows so
that others can take that knowledge and spread it.
In health care, this is particularly true for, as we
have seen, there are ‘anly limited allocations for
health services and most health improvements must
come from changes in people’s behaviour. Teaching,
however, is not merely to pass on information but
rather to help others to put that information to use.
The whole study of informal education has begun to
identify ways in which the vast numbers of people
who still live outside the highly sophisticated world
of concepts of Western science and technology can
still profit from their findings. Educational techniques focus on a process of interaction between the
teacher and the student in which both people are
able to learn and work together to consolidate their
ideas. There is a need to identify, articulate and
develop this process and teach others to use it. A
major component of a good community-based
health programme is a teaching component where a
corps of community
people are trained to
understand this process and to use this knowledge to
effect change in the community.
An important part of restoring human values and
dignity is creating independence from the forces
which previously have denied this realization. As has
been discussed, foreign aid often has been a major
contributor to preventing this growth of confidence
both at a national and local level. Foreign aid all too
often has meant that programmes take the shape
which the donor has defined without regard to the
views of those affected by the programme. It has,
also, meant that foreign personnel supervise and
direct the activities of the programme. This has
caused much bitterness among financial recipients
and has blocked the ostensible goal of the
programme which is “to have the community take
responsibility for its own health”.
At the same time, it must be noted that nearly all
the successful community participation programmes
outside countries like China have had various
degrees of foreign funding. Funds on a national or
local level give needed impetus and resources which
can allow community-based health programmes to
build deep roots in a comparatively rapid time
period. But they also, because of little understanding on both the part of the donor and
recipient, can completely flood the programme and
wash away any noticeable improvements. Foreign
aid is useful and acceptable under carefully-defined
and specified conditions. A community-based health
programme recognizes this fact and works in tandem
with the donor agency to spell out in detail how this
aid can be a positive rather than a negative force.
The measurement of health status alone as an
indicator for the success or failure of communitybased programmes is not very useful. Not only are
the statistics unreliable, but also, this criteria
emphasizes the Western science and technological
factor of health care rather than the development of
the potential of human beings to improve their own
health. We must also recognize that is very difficult
to measure how much or how little a community
participates. Attendance at a meeting or a vote to
accept a community health worker by no means
indicates a strong understanding of the goals and
objectives of the programme. Success of the
programmes can only be measured over a long period
of time as changes in community attitudes become
apparent. These changes may be evidenced in a range
of activities,. from demanding better and more
appropriate health services from the government
clinic, to the establishment of a profit-making goat
cooperative. Improvement in health status will most
likely be seen as the programme begins to develop.
In a community-based
health programme, the
objective of an evaluation is not to see how the
programme compares with other similar programmes. It is to help the community to understand
how it is progressing along the lines which it has laid
down for its own development.
therefore, must reflect the goals and values of the
community, not of the experts. Professional opinion
through dialogue can help shape an evaluation and
assist in techniques to measure the suggested
however, is part of the
education and growth process of the community. A
community-based health programme recognizes its
success in how the people, not the professionals,
judge the programme and in the evidence of
responsible community
leadership which reflects
improvements for all groups within the community.
Does a community participation strategy represent a
real alternative to the present inadequate health care
apsystem and i*ts concommittent
proaches? Can the human factor make a larger
impact on improving health for the millions of
people who now live in ill health and poverty than
the provision of more and modern technology? The
evidence is not yet conclusive but we do have some
how these questions might be answered.
Another friend, Sister Mary Grenough, who has
spent the past twelve years working in the rural
Philippines, travelled last year to visit several
health programmes throughout
Africa and Asia. In closing, I quote her evaluation of
this experience.
“In each of the countries I visited, in each of the
programmes I became acquainted with, what really
make:’ the programmes effective and what really
urged government and oiher groups to pay attention
to w+at is happening is the human factor. Time and
again, the effectiveness of programmes did not
depend so much on the amount of money spent, or
on the technological equipment, but on the human
factors: concern, motivation,
critical analysis, a
steadfast commitment and focus on people’s needs
and people’s resources”.
Community participation in health care credits the
value of people and their ability to improve their
own lives. If it is true that development and health
is about people, then we must find ways of giving
people the priority.
is the Associate Director of Educational Strategy Studies at the International Council for
Educational Development, Essex, Connecticut, USA. Formerly Head of the Department of
Educational Administration,
Dacca University, Bangladesh, he has published a number of
studies on non-formal education in rural populations.
is Chairman of the Centre of Social Medicine and Community
Health at the Jawaharal
Nehru University in New Delhi, India. With an early career as a tuberculosis specialist, his
interests now lie in the political economy of health, on which he has written numerou?
is a nurse lecturing in community health at Queen Elizabeth College, University of London,
UK. Her MEd thesis discussed the relevance of community
development to community
health programmes and her doctoral thesis concerned the development of the village health
worker. She has served as an evaluation consultant to a village health worker programme in
is a communications
specialist, at present at the United Nations. With the National Food
and Nutrition Commission in Lusaka, Zambia for some years, he had done pioneering work
in the field of communications
in developing countries and has been associated closely with
the Dag Hammerskjold Foundation in Sweden.
is a member of the Participatory
Research Project for the International Council for Adult
Education in To,ronto, Canada. He was a member of the coordinating committee for the
Mfu Ni Afya health education campaign of the government of Tanzania, with responsibility
for evaluating the campaign’s activities.
Mary Racelis
is Director of the Institute of Philippine Culture and Professor of Sociology at the Ateneo
de Manila University, Philippines. A Filipina with special concern about urban poverty and
women, she has written extensively
about these problems and has served as a special
consultant to UNICEF, working in the Asian region.
is a nurse, working with Yayasan Indonesia Sejahtera (Foundation
for a Prosperous
Indonesia), and is specifically
interested in training programmes. With 10 years’ field
experience in community
health programmes in Indonesia, her early experience was in
Solo, working
with Dr. Gunawan Nugroho, who established a community
programme which has received wide publicity by WHO.
RI FKIN Susan B.
is a Researcher on Community
Health Programmes for the Hong Kong Christian Council
and an Associate in Research at the Centre of Asian Studies at the University of Hong
Kong. She has served as a health education officer in Zambia and a consultant on health to
the Christian Conference of Asia and has written on health care in China and on
health programmes in Asia.
Maria das Merces G. is a recently graduated PhD in Sociology who did her thesis work at the Institute of
Development Studies at the University of Sussex, UK. She is a Brazilian, who has worked
in the programme she describes in this volume.
is Professor of Health Care Research at the Swedish Medical Research Council. In addition,
he is a consultant to the Swedish Agency for Research Cooperation with Developing
Countries (SAREC), and has served as Professor of Paediatrics and Director of the
Ethio-Swedish Paediatric Clinic in Addis Ababa, Ethiopia.
is Director of the Hesperian Foundation in Palo Alto, California, USA. A school teacher
who has spent 12 years helping the villagers of a remote Mexican village establish a
comprehensive health care programme, he is the author of Where There is No Doctor, a
villagers’ self-care manual which is being used throughout the world.
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