Participation of the community is essential for successful implementation of healthcare schemes
Health practitioners have come to realise that the top-down approach has not yielded desired results in the development paradigm. They are now restructuring social and development practices to create a sense of ownership in the target community to the programme. This has meant significant involvement of the community for design and delivery. Special care has been taken by programme designers to include more vulnerable sections of the society.
In case of healthcare delivery interventions, the focus on involving the community has been even more evident. This is partly because the success of a health programmes depends largely on its acceptance by the people.
New insights in healthcare
Preventive health programmes like immunisations are aimed at the entire population and are focused on otherwise healthy people. Thus, the onus of making these programmes a success shifts from people to provider, as healthy people have no immediate need for seeking out health services. Compulsory measures have often backfired, causing a shift to communication and education to increase reception of the programme. Volunteers drawn from the community for awareness and outreach have been vital for the process.
The thrust can be traced back to the declaration of Alma Ata in 1978 that was signed at the International Conference on Primary Health Care. It took cognizance of social and economic causes of ill health and focussed on issues of accessibility and affordability thereby linking health to development.
Primary Health Care (PHC) was recognised as an integral part of every country’s health system and central to social and economic development. Comprehensive health care was the proposed solution. It stressed on community participation and a spirit of self-reliance, on the principles of equity, use of appropriate technology, affordability and sustainability of health systems. However, global and top driven interventions found little or no place in the idea of PHC.
This has also led to change in the understanding of health, which is now being recognised as a function of social, economic and cultural forces. Concerns of health are not solely confined to the Ministry of Health. Effective convergence between various departments has become imperative.
Involving the community
People’s access to healthcare, education, conditions of work and leisure determine their chances of living fulfilling lives. Addressing rural health concerns through the National Rural Health Mission (NRHM) (now National Health Mission) is based on the principle of convergence with other determinants like water, sanitation and nutrition.
NRHM has also adopted the model of ASHAs (Accredited Social Health Activists) and ANMs (Auxiliary Nursing Midwives) who function as community health workers. It seeks convergence with Ministry of Women and Child Development’s ICDS (Integrated Child Development Services) that also utilises the services of aanganwadi (child day care centres) workers to increase their outreach.
These community health workers, drawn primarily from the same village, have had a tremendous impact on nutrition, reproductive health and contraception, immunization, and safer deliveries. They have also accelerated behaviour change - hand washing, use of ORS, benefits of breastfeeding, safe sex and calorific norms. Polio Eradication Programme also successfully utilised the outreach and networks of community volunteers to achieve the status of polio free India.
The success of this model on a national scale has also been replicated to some extent by independent non-profits, albeit at a micro scale. Perhaps the first such experiment was by adopted by the Society for Education, Action and Research in Community Health (SEARCH) located in Gadchiroli, Maharashtra. It got the leaders of the community to sign participation agreements and trained local women as Village Health Workers (VHWs). Initiating a dialogue with the community to listen to their problems, conduct studies with them, inform them of evidence and then engage with them is a priority for the non-profit.
Rajiv Gandhi Mahila Vikas Pariyojana is another good example of the model of community ownership and participation by women. In fact, the entire design of the programme is to help poor, rural women through community institutions in the form of self help groups (SHGs).
Within this programme, community based health care is provided through the Swasthya Sakhi Programme. Volunteers are identified from within the community to train as Swasthya Sakhi (friends for health) and undergo regular training and meetings to facilitate awareness and ensure women’s access to healthcare institutions. Studies by the organisation have noted improvements in the number of women seeking ante-natal care, consuming iron pills for anaemia, and being trained in good behavioural practices.
While these programmes have effective outcomes, they can be fraught with several problems. Communities are never homogenous - they include differences in status, access to resources and power imbalance. This may result in a scenario where the powerful may dominate the programme and lead to shift in its priorities.
To combat this, it’s essential that programmes let locals function as investigators and researchers. Participatory mapping and modelling can be used to make social, health or demographic maps. This can be useful tool for ‘silent’ people in the community to express their views.
Similarly, institutional or Venn diagramming can be used for identifying individuals and institutions important in and for a community, and their relationships for understanding power structures. Even role play and theatre can be used to explore realities.
These recommendations can run into problems - ranging from lack of money and resources, to simplistic ideas about community. However if these constraints are successfully overcome then community based health programmes can go a long way in addressing rural health issues and outcomes.
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