COMMUNITY PARTICIPATION IN

HEALTH, FAMILY PLANNING AND

DEVELOPMENT ACTIVITIES A REVIEW
OF INTERNATIONAL EXPERIENCES

Final Report

Abbas Bhuiya
Fatima Yasmin
Farida BegUm
ETkz!idur Rob

Contract No.Cl96.33A

International Centre for Diarrhoeai Diseases Research

Bangladesh
and
The Population Council

1996

This project was suppotied by the Population Council’s Asia and the Near East Operations
Research aad Technical Assistance (ANE OR/TA) Project. The ANE OR/TA Project is funded
by the US Agency for Iatewational Development, Office of Population, under Contract
No. DPE-3030-COO-0022-00, Strategies for Iwproving Family Planning Service Delivery.
 CONTENTS

Introduction . . .. .. . . . _. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Statement of the Problem.. ........................................................................................... .

Comprehensive Rural Health Project (CHRP), Jamkhed, India.. ............................... .6

Kamataka Project for Community Action in Family Planning (KPCFP), India.. ... ..lO

Community Participation Through Self- Introspection Mawas Diri:

A Tool to Stimulate Community Participation .. . .._....._.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

An Integrated Rural Health Project in Saradidi, Kenya .,......................*.................... 17

Mobili~alioil l‘or Nutrition in ‘I‘anzania (‘fhe Iringa hutrition Project) . . . . . . . . . . . . . . . . . . . ..I?)

Community Involvement in Health Development: Caranavi District, Bolivia..........23

Comilla Development Model, Bangladesh.. .............................................................. 28

Chakaria Community Health Project (CCHP), Bangladesh .................................... 31

Conclusion .. . . .._.. . . . .. .. . .. . . ..___,__._. . . . . . .. .. ... .. . ... . .. .. . . .. . . . . . . .3 5

13ibliogr;lpliy .. .._......_._. .._...__....._....... .._. ._........_........... ..iS

Introduction

Family planning and maternal-child health programme in fjangladesh has achieved a

commendable success in the recent past. This has mostly been achieved through a large
scale service delivery system of the Government with donors’ support and cooperation
from non-government organizations. Currently, there are 35.000 family planning service
outlets in the country, a large majority of whom are organized at district level and below.
The activities are most intense at the union level and below, with 3,000 Family Welfare
Centres (FWC), 1,275 Rural Dispensaries, and 23 Mother and Child Welfare Centres
(MCWC). At the village level, basic MCH-FP services have been provided by the FWC
~td’f’al satellite clinics at the rate of 30,000 clinic days per- month. Additional scrviccs at
door-step have been provided by 23,500 Family Welfare Assistants (FWA) of the
Government and over 8,000 field workers of the non-government organizations.’ The
urban areas are mostly devoid of any effective and organized service delivery systems
from Government and non-government organizations.

Statement of the Problem

While the level of success as measured by increased acceptance of modem methods of

family planning and MCH services is improving every year, relevant quarters are
concerned about the programme, its financial and social sustainability.The massive
infrastructure developed over the period is mostly maintained with donors’ support. It is
apprehended that external support at the current level may not be easily available. The
other major issues in this context include achievement of a replacement level of fertility
within a stipulated period and improvement of quality of MCH-FP services. It is widely
believed that most of the concerns will be taken care with an effective community
participation

The importance of community participation in MCH-FP programme has also been

underscored in the USAID strategic options proposed for the period ending in 2005.’ In
attaining the visioned objectives a series of institutional and programmatic components
have been identified. The major components include social institutions and educational
programmes, and decentralized health system. Involvement of the community in some
form or other has also been outlined in the report to address the above two components.

While there is little scope to argue to the contrary, it is clear that there is a lack of
understanding about how community participation can be ensured. What will be the

‘Haider S. H., Streatfield K. and Karim M. A. 1995. Comprehensive Guidebook to the Bangladesh Family
Planning-MCI-I Program. Research Evaluation Associates for Development (READ), The Population
Council, Ministry of Health and Family Welfare, Dhaka.
’ Pi~~klmrnI-. ei ul. 1995. The Bangladesh Family Plannln s and Iicalth Services Project: Strategic Optlons
Report. L’SAID (R~A-USAIDIBanglndesh-96-p-002).

3
degree of participation? Participation in what aspects of the programme? What will be the
relation between the programme and the community?

The theme of community participation has been incorporated in the agenda of the
Government and non-governmental organizations, in the context of primary health care,
since the Alma Ata Conference and it was defined as one of the pillars of primary health
care. Despite some attempts in Bangladesh, the success has so far been limited.

In the context of MCH-FP programme, community participation has so far been

attempted through involvement of the representatives of the local government or non-
traditional groups/committees created by either Governmental or non-governmental
organizations.3 Though the community members participated in such initiatives, their role
is limited since the control of the programme in terms of resources, planning,
implementation, monitoring and evaluation always held by the staff of the implementing
agency, be it governmental or non-governmental.

Another aspect of the current strategy for ensuring community participation is based on
the assumption that the programmes initiated with external support will, after sometime,
be left with the community for operation. There has been little evidence to lend support to
this assumption. Moreover, the tradition in this culture is just the opposite.

The Chakaria Community Health Project of ICDDR,B has been an exception where
attempts have been made to activate the indigenous village-based self-help organizations
to take health initiatives. The project has so far succeeded remarkably in mobilizing
community to define, plan and implement health actions with virtually no material
support from the project4

The task of ensuring community participation is a challenging one and deserves special
attention. A mere invitation to the community members for participating in a programme
brought in by outsiders is very simplistic and ignores the complex issues like social
psychology, culture, and various other social issues. Bangladesh has a long tradition of
community initiative in establishing schools, building roads, markets, mosques, etc. Most
of the now nationalized schools were once built through community initiatives and were
used to be maintained by the community. Even now most high schools are managed by
the communities. There has been over 6,500 registered village-based voluntary
organizations engaged in various welfare activities in the country.’ It is reasonable to

‘Committee at union level has been one such example. USAID-supported local initiative project which has
made significant impact on family planning acceptance in rural Bangladesh, also falls broadly under this
category.
4 Bhuiya A. 1996. Rethinking community participation. I. Health initiatives by indigenous self-help
organizations in rural Bangladesh. (Manuscript), ICDDR,B; Dhaka.
‘Government of Bangladesh. Directory of Voluntary Social Welfare Organizations in Bangladesh.
Bangladesh National Social Welfare Council, Dhaka. Bhuiya A. 1996. Characteristics of village based self-
help organizations in a rural area of Bangladesh. Manuscript, ICDDR,B; Dhaka.

4
think that community participation can be initiated for health and family planning related
activities.

Thus, it is worth to carry out action research in this regard to find ways to:

1. activate community initiatives to improve maternal and child health and family
planning status;

3
-. establish a link between the community initiatives and the relevant public and
private sectors;

3. ensure cost sharing by the community members in MCH-FP activities.

Before designing any action research to fulfill the above objectives, it was considered
appropriate to review various programme models, preferably on health and family
planning, with a reasonable level of success in community participation. Thus, a literature
review was done during July-October 1996 with the objectives of identifying a range of
models used for increasing community participation and their experiences in terms of
implementation, management, financing, monitoring and evaluation, and sustainability in
both rural and urban areas. Attempts were also made to identify set of indicators to assess
the level of community participation in these programmes. The present report documents
the results of the said review.

The review was done on the basis of literature available in POPLINE and MEDLINE
databases and other materials available in Dhaka. The search for literature was carried out
by using appropriate keywords to achieve the review objectives. After a preliminary
reading of the material, it was categorized on the basis of five dimensions. The
dimensions included the extent of community participation in (1) initiating the project,
(2) needs assessment, (3) defining, planning, and implementing actions, (4) monitoring
and evaluation, and (5) resource mobilization. The best eight projects that scored high in
terms of the above were reviewed extensively. However. all literature scanned in
connection with the review have been listed in the bibliography.

The eight projects thus selected were:

1. Jamkhed Comprehensive Rural Health Project (CHRP), India

2. Karnataka Project for Community Action in Family Planning, India

3. Integrated Rural IHealth Project in Saradidi, Kenya

4. Mawas diri Community-based Health Care Systems and Training Programme,

Indonesia

5. Mobilization for Nutrition in Tanzania

5
 6. Community Involvement in Health Development: Caranavi District, Bolivia

7. Comilla Development Model

8. Chakaria Community Health Project of ICDDR,B, Bangladesh.

A brief description of all the projects with their salient features is presented below:

Comprehensive Rural Health Project (CHRP), Jamkhed, India

The project is located in Jamkhed in the Ahmednagar district of Maharastra state and
began in 197 1. It was initiated by an Indian couple with background in surgery. One of
the major goals of the project was to provide health services appropriate to the conditions
of rural life and draw on locally available resources to the maximum extent possible.

The project made tremendous positive impact on health of the population by reducing the
incidence of chronic diseases, leprosy, tuberculosis, and malaria. The acceptance of
preventive public health measures and adoption of appropriate health behaviour has
improved resulting in substantial decline in mortality,. Among others, the project
activities also have contributed in improving the position of women and poorest segment
of population, and generated self-reliance among the villagers. The project was also very
successful in developing village based organizations to play active role in all aspects of
development including health.

Over the period the project changed its role by reducing the intensity of the inputs and
currently playing the role of a facilitating organization in maintaining network among the
village-based organizations. It is claimed that the activities have been maintained by the
village-based organizations even after reducing the project inputs.

Initiation of the Project

The project was initiated by individuals from outside the project area. At the beginning,
the founders were contacted by one of their friends from the locality, who knew them for
quite sometime. He could mobilize local people to show that the project will be
welcomed by the community and all possible supports will be provided. This was
possible because of the reputation of‘the couple nd the rxcd for curative health services
in the area. The community members expected that a good health service facility will be
established in the area from which the community will be benefited.

6
Process and Level of Community Participation

The project activities started with a curative service facility which was established with
material support from the community. The community members started to get benefit
immediately. As the process went on, it was realized that the marginalized low-caste
community members were not receiving the most out of the project. It was also difficult
to bring them together with the high-caste and rich members of the community.

Attempts were made to identify any activities carried out by people of various castes and
socioeconomic groups. Volleyball game was one such activity. By using the example of
the game and mass participation in it, a proposal to form Farmers Clubs (FC) and a
women organization, namely, Mahila Mandal (MM) was made. Eventually, many FCs
and MMs came into existence. The members of the FC and MM were supportive of the
services provided by the health workers of the CRHP. They helped in disseminating
health messages and in mobilizing the community for development efforts.

Leadership and Decision Making

There were no formal links between the project staff and various village groups, such as
farmers clubs and women’s clubs whose formation was encouraged by the project. The
villagers provided land and other supports for building the facility at Jamkhed. The
Project Directors offered advice, if requested, but the initiatives and the decisions taken
have been reported to be the sole responsibility of the club leaders.

Although there are no formal ties with the Government, the project actively sought the
cooperation of all the government agencies in the area, and had established an excellent
working relations with them.

The Village Health Worker (VHW) became a major link between the project and the
community. The VHW proved to be a great help in generating community involvement.
This was facilitated by her, she being a resident of the village.

The choice of activities undertaken under the project was made through a continues
dialogue between the project staff and the villagers. Special efforts were made to ensure
that the views and needs of the poorest members of the community would also be heard.
As the workers gained credibility, the people became more open.

Activities

The project activities can be divided into two broad categories:

1. Health and family planning: Simple primary health care, care of expectant and
nursing mothers and birth delivery, care of pm-school children, control of chronic
illness (leprosy and tuberculosis), prevention of blindness, treatment of physically

7
 handicapped, follow-up and treatment of emergencies and family planning side-
effects;

2. Development activities: Income-generating activities to relieve economic pressure

during seasonal unemployment or under-employment, provision of improved animal
health care and alternative sources of energy, such as wind, solar, biogas, and
arranging non-formal education.

Financing

Funding for the capital costs at the beginning was provided by a missionary group. The
local community donated land, building materiai and manpower, representing some fifty
percent of the total capital cost estimated to be 17s $ 140,000. As regards operating cost,
it was made clear at the outset that the health services, unlike free services from the
government hospitals, would be provided on a “ fee for service” basis. The charge would
depend on the economic condition of the patient. This arrangement was generally
accepted, and often community members collected money to cover the cost of chronically
ill patient needing costly surgery. It took four to five years, until credibility was
established, for the health services to become virtually self-supporting, during which
time, the project received funding from outside private sources. The amount of income
from various sources, including fees from patients was sufficient to cover the core budget
of the health care offered by the project. The biggest element of the operating cost was its
mobile services. The project needed outside funding support to run its credit operation for
income-generating activities.

Special Feature

The activities of the FCs and MMs on primary health care were unique in India. These
organizations were supportive of the services provided by the health workers and helped
develop self-reliance among the community members in health and other matters. They
also helped in the spread and acxFLti,,
+r-ce of new ideas and technology. The club members
and the project staff worked together, planned dxildcarried out programmes which
benefited the members as well as others in the village. It was through these clubs that the
community got involved in the health programme. The volunteers of MM and FC played
an important role in decreasing the level of superstitions, changing attitudes and teaching
good health habits. encouraging small family norms, motivating other villagers to form
clubs like theirs in addition to the health-related activities. The volunteers were involved
in many educational, agricultural and economic development programmes by way of
organizing non-formal educational programme, mobilizing and organizing women to get
bank loans to start self-employment schemes and take collective responsibility for its
repayment.
Achievements

The project has been operating more than 15 years, Its directors summarized its
achievements as follows:

“Project villages have been remarkably successful in reducing the incidence of chronic
diseases, leprosy, tuberculoses and malaria. Timely detection and treatment of illness, and
preventive measures such as immunization for children have effectively improved the
health status of the villagers. There has been a marked decline in infant mortality to less
than 40 per 1OOO.,compared to the State average 110. There has also been a sharp decline
in maternal mortality and morbidity. The crude birth rate in the project villages was
around 2.5 per thousand population, compared to 30 per thousand for the State as a whole.
It had also contributed in improving the position of women and the poorest member of
the community, and standard of living among the beneficiaries and promoting self-
reliance in the community, A study on the FCs and the MMs revealed a significant
positive role of such organizations in the rapid spread and acceptance of new ideas and
technology in the community.”

Success Factors

One of the important factors for the success of the project has been the creation of the
FCs and MMs. These were the means of organizing communal support for the project and
of channeling the energies of the people to find their own solutions for their problems.
The development of confidence in their ability to solve their problems jointly has been a
major outcome of the project and was crucial for achieving self-reliance.

In addition, the personalized attention given throughout by the project directors at the
individual and at the community level was also very important. Other factors included:

l Local support;

l Good- will generated among local people;

l Local involvement and their acceptance to pay for curative service;

l Flexibility in planning and implementation in response to constant evaluation;

l Simplification of technical and administrative procedures;

l Freedom from intervention by outside agency.

9
Obstacles

Attitude of non-cooperation from the indigenous medical practitioners was the main
difficulty faced by the project. These practitioners were feeling threatened by the project
work. This was overcome by virtue of the confidence the project earned from the
community members.

Sustainability

Through the work at Jamkhed, many communities, especially those with active Mahila
Mandals (MM) have become self-reliant. As reported they depend on CRHP only for
secondary and tertiary technical support and networking. Since 1989, CRHP has been
gradually withdrawing, because many of the community organizations have become self-
reliant. Many Mahila Mandals are functioning well and mobilizing resources on their
own. They organize health camps and continue to monitor the health of children in the
village and carrying out many income-generating activities. They work closely with the
government ANM (auxiliary nurse midwife) to ensure the maternal and child health.6

Karnataka Project for Community Action in Family Planning

(KPCFP), India

The project began in 1979 with focus on family planning and maternal and child health. It
was derived from an earlier project on awareness development which was, in fact, started
in 1974.’ During the first phase the project focused on educational and social and
development activities. In its second phase from 1979, the project aimed at increasing
community participation in family planning and MCH. The project was implemented by
the Family Planning Association of India ( FPAI ) in Belgaum, a division in the northern
part of the State of Karnataka covering a population of nearly 250,000 living in over 150
villages. A second revision of the project activities was made in 1983 with increased
emphasis on establishing and strengthening local institutions. The project made
significant improvement in family planning practices and in attaining self-reliance by the
villagers in planning, implementing and financing community activities.

The project followed a three-stage process. The first stage was the action by the FPAI
alone followed by the second stage in which the community took action in collaboration
with FPAI. In the third stage, the community members took their own initiatives by
themselves.

Objectives of the Project

The three main objectives of the project were to:

” Arole M. and Arole R. 1994. Jamkhed: A Comprehensive Rural Health Project, Macmillan Press Ltd.
’ Wolfson M. 1987. Communty Action For family Plannin g, Development Center Studies, OECD, 1987

10
 l increase community involvement and support for small family norm through
education and social and developmental activities;

l increase family planning acceptance;

0 improve MCH programme to support family planning and promotion of

women activities and child care;
l help community to develop skills in planning, implementing and sustaining
self-help activities, based on their felt needs.

Organization

The activities were carried out by a large number of intensively-trained professional staff.
The members of the staff were directed by a three-member liaison committee of the
volunteers appointed by the FPAI Regional Office in Dharwad, a university town near
Belgaum. Both volunteers and the project staff were guided by the FPAI National
Headquarters in Bombay.

There were 13 administrative and supervisory staff at Dharwad. The six field units in
each of the six villages were manned by four community welfare workers (two men, two
women), a field organizer and an auxiliary nurse-midwife( ANM ). Each unit was
supported by an honourary medical advisor who was a local private practitioner. A
change in the project strategy was made in 1983 which resulted in a reduction of
personnel from 84 to 6 l? and the community welfare workers were moved from
headquarters to the villages with a view to strengthening the community endeavours.

Local Voluntary Groups ( LVGs ) constituted the backbone of the project. They provided
the structure for enabling the community to take action to deal with their various
development needs, including family planning practices. The process of forming LVGs
was extended in almost all the project villages. The most commonly formed groups were
youth clubs ( Yuvak Mandels) and women’s clubs (Mahila Mandels ), followed by
elders’ clubs, cultural clubs, and farmers’ fora.

Project Implementation

The educational activities, the core function of the project, were initially carried out by
the project field staff, and later by the project staff and the LVGs together. As the pro.icct
progressed, the LVGs took full responsibility both for planning and carrying out most
educational activities. The various activities carried out under the project included
mobilization of the community by way of formation of voluntary groups; training of
group members; and carrying out activities by the trained group members.

11
Relations with the Government and Voluntary Agencies

There was a good cooperation between the project and government departments,
particularly with the staff responsible for the PHCs. The relation with the government
staff was considered very important and complementary in the work and also to ensure
sustainability of the programme after the project ceases to operate. To help establish good
rapport and liaison with the health staff, a series of meetings were held between the FPAI
and the Government at different levels. Initial misunderstanding, especially at the field
level, was gradually overcome, and the government health workers later recognized that
the project supported their work. The arrangement worked well for both sides: the
contraceptives required by the project were provided by the PHC, and the project helped
the PHC with other medical supplies. Camps for immunization, IUD insertion and
sterilization were organized jointly by the project and the government staff.

In the early days of the project, the Government of Kamataka passed a formal order
agreeing to its implementation. This has facilitated cooperation of the government
departments responsible for development activities, such as the Block Development
Office, Agriculture, Education, and Women and Child Welfare, and the LVGs.

The project has made successful efforts in identifying non-governmental bodies of all
kinds that could be helpful in keeping the project going and in expanding its activities.
Useful working relationships had also been established with the state Adult Education
Council, the Rotary Club, the Lions Club, the Indian Medical Association, etc. that
helped organize many coordinated activities, notably health campaigns and camps to
address special health problems. The project had also been effective in securing the
cooperation of the local religious committees existing in most villages.

Achievements

Between 1979 and 1984, the total number of LVGs rose from 13 1 to 454 and the number
of members from 3,000 to 16,000. In 1984, sixty percent of the MCH sessions were
organized by the LVGs alone, and nearly 40 percent jointly with the FPAI. The
community played a still more active role in the area of family planning-- both family
planning education and provision of services. Trained community leaders motivated the
couples to accept the small family norm and to use contraceptivesThe educational
activities, initially which was entirely the initiative of the project staff, had later been
increasingly planned and carried out by the LVGs. It was also found that the average
attendance at educational activities carried out by the LVGs was consistently higher than
that of the FPAI-conducted sessions. One of the most significant achievements was that
more than one-third of the project villages became self-reliant in planning, implementing
and financing community activities.

12
Financing

The project had various sources of funding : the FPAI; the Government and other
agencies; and the LVGs. It was the intention since the outset that the FPAI support would
be gradually phased out, and to be replaced by the resources generated by the community
members themselves either from their own resources or from outside. For the five-year
period (1979-1984), the own input of the communities to their activities under the project,
made through the LVGs, was higher than that of the FPAI. This testifies the ability of the
KVGs to assume an increasing share of cost of the community activities, partly from their
own resources and partly by securing Government or other support. By 1984, the LVGs
and the Government were contributing roughly an equal amount.

Principal Positive Contributory Factors

The existence of the population awareness project in the area undoubtedly facilitated an
easy start of the project and shortened the length of the preparatory phase. The FPAI had
acquired considerable knowledge of the area, the people and their customs, perceptions
and needs, and their potential for organizing themselves to improve their situation.
Harmonious relationship among the different ethnic and religious groups in the political
sphere assisted the development of a community spirit.

The relocation of the community welfare workers from taluk headquarters to the villages
strengthened the relationships between the project and the communities, and enabled the
prqject staff to become more familiar with local needs and problems. The incorporation
of modern ideas into traditional forms of entertainment provided a convenient way for the
project to get its ideas across to the community.

Problems Faced by the Project

The following problems were faced during implementation of the project:

l The undemocratic social structure and practices in the villages made it

difficult to get the participation of the very poor and the lower castes;

l The low status of women and their limited involvement in social activities
hindered their participation.

l The lack of planned and sustained efforts on the part of the LVGs to mobilize
local resources hampered the community activities.

Sustainability

It was not clear from the document whether the FPAI inputs were totally withdrawn from
the area and its consequences. Thus, no clear judgment could be made about the level of

13
sustainability of the activities. However, it is likely that the skills acquired by the local
organizations in needs assessment, identification of solutions, and implementing
programmes with local resources will remain with them and will be useful for any
community initiatives in the future.

Community Participation through Self- introspection Mawas Diri: A

Tool to Stimulate Community Participation

The Indonesian Department of Health took this initiative to design a participatory

monitoring tool with an aim to alleviate health problems through effective community
involvement. A local NGO was entrusted to do the job in 1984. The approach proved to
be effective in ensuring community participation’ .

Goal

The basic goal of the Mawas Diri tool was to ensure community involvement in solving
community health problems and to achieve overall community development.

Intervention Strategy and Implementation

The approach was based on a problem-solving cycle which began with the detection of a
problem by the people themselves and went through the steps of identifying solutions,
taking actions and evaluating effects on the problems.

To facilitate the programme the people developed a simple self-survey form which listed
the various aspects of life related to their family and community health welfare. These
aspects included a healthy environment, a healthy way of life and healthy socioeconomic
conditions. A healthy environment covered the home and the outside yard. Issues within
the home included provision of light, floor, ventilation, roof, and cleanliness. The
household environmental issues included drainage, garbage disposal, animal and pets,
and plants. After the indicators were developed, a minimal standard was set for each
component to classify a condition as good or not good. Equipped with the form, trained
village workers (VHWs) visited a specified number of families in their neighbourhood,
usually between 15 and 20. They evaluated each item on the form using a simple score of
‘good’ ‘not g:ood’, and ‘not relevant’ whether a home and its environment met the
predominant standards. After visiting all the families the forms were processed. Each data
collector added up the total number of ‘good’ (G) and ‘not good’ (NG) families he had
visited to make the problems evident.

The next step was to discuss the three most common problems for future actions. TO
decide which three of the problems to tackle first, the seriousness and extent of the
problem and the capacity of the community to solve them by using local resources were

* Johnston, M. 1990. Mawas Diri: a tool to stimulate community participation. Health Policy atd Plat7t7ing.
5:161-166
taken into consideration. Data were collected every three or four months and compared
with data from the previous three months. If the number of ‘not good’ decreased it was
determined that some progress had been achieved.

Achievements

The Mawas Dir-i tool had proved attractive to a diverse group of people including mid-
level policy-makers, village officials, government technical services and VHWs. Through
this tool a village can collect its own data and use it to draw up realistic plans for
development. This can help overcome a major problem in the Indonesian planning
process in which villages are encouraged to submit their own plans for funding. The
process also motivates the community to tackle creatively the problems which they
themselves detected. The approach also had possibilities for promoting institution-
building by strengthening the functions of the local bodies. Government technical
services said that Mawas Diri could assist them in a number of ways. The data and
prioritization of problems provided them with specific information on the location and
extent of problems in a certain area. It assisted them in their planning activities, and it
enabled them to make more effective allocation of funds and facilities in government
programmes. The Mawas Diri approach proved that community participation is not only
possible in all stages of a development programme but also increases the quality of
activities and contributes significantly to human development. Through the Mawas Dir-i
approach people gain skill in looking critically at their environment, detecting problems
and prioritizing them, in planning, implementing and monitoring improvements.
Through this process the people develop initiative and creativity. Most important of all,
by this working programmes people work in their choice, gain greater confidence in their
right and ability to control their lives.

Community Involvement

The community was directly involved from the beginning since the Mawas Diri survey
form was designed by the villagers in cooperation with a health or community worker. It
was the community members who selected the aspect of life, component, and indicators
to monitor. Lively and lengthy discussions usually took place when the form was
designed. They had developed a strong feelings of mutual responsibility and commitment
during the process.

Leadership and Decision Making

The meetings were facilitated by the villagers with assistance from the project staff.
However, the definition of the actions and their implemenation was determined by the
villagers themselves.

15
Relation with the Government

The Mawas Diri tool was implemented by the request of the Indonesian Department of
Health with the help of YIS a non-governmental organization which was involved in
community health and development. This support was helpful in achieving success.

Special Feature

The unique feature of the Mawas Diri tool was that the problems which can locally be.
solved were selected. Thus, the solution of the problems had minimum dependence on
external resources. The external assistance was mostly limited to the introduction of the
participatory monitoring system. The process was also successful to generate community
interest in solving their own problems by themselves which was itself an empowering
process for the community members.

Financing

The Indonesian Department of Health and the Australian International Development

Assistance Bureau funded the programme. There was no significant attempt to raise
funding with a view to sustaining the activities after the closure of the project.

Factors Contributing to the Success of the Project

The involvement of the community members from the beginning was an important factor
in making the project a success. Identification of the problems by the villagers and
finding a solution by themselves were also important. The implementation of the action
and the monitoring of the progress by the community in a regular basis played a key role
in making the programme a success.

Obstacles Faced by the Project

One of the problems faced was the reliance on literate people who could fill the form and
who could work with numbers. Another problem was to maintain the routine in
collecting data and enthusiasm of the community members.

Sustainability

Village heads considered that the tool can help them obtain reliable and relevant data as
well as motivate the community to tackle some of their problems. It was not clear 110~
long the activity would have been maintained after the closure of the project.

16
 _- _.~ .__---

An Integrated Rural Health Project in Saradidi, Kenya

The project was initiated in 1979 as a self-help for health and development by the
community members in Sararidi, Kenya, in response to the problems faced by the
community.’ The activities included health and income-generating activities. The
activities were carried out with material support from within and outside the locality. The
project was still running 10 years after the beginning more or less on its own. The project
believed to had contributed in reducing mortality by controlling malaria and other
immunizable diseases.

Goal

To provide the target group with basic health services that would be appropriate to the
conditions of rural life and draw on locally available resources including community
participation to the maximum extent possible.

Intervention

The programme ensured simple drugs to be available to the people and provided
preventive and and promotive health services backed by health education. The income
generation was mainly agriculture-based. The programme was based on church
congregations. The project introduced village health committee and village health helpers
to implement the project activities.

Rapport Building and Communication

The church group took the initiative to mobilize the whole of the surrounding community
to be involved in health and development activities. In 1979, they selected 13 people ~1~0
were given the task of taking the activities to other church congregation, denominations,
and other readers. They did it so effectively that within three months most people became
aware of what was being planned and their role in it. The first community meeting was
open for all members of Saradidi community where the problems facing the community
and their possible solutions were discussed.

Financing and Sustainability

Interventions and support from outside SRDP was significant. The programmes were
dominated by external resources resulting in a weak role of the community members.
Thus, the prospect of self-reliance remained bleak. Any plan to generate own resources
from the community to sustain the activities after withdrawal of the project was not
apparent.

‘)Kaseje, D. C. 0 and E. K. N. Sempebwa. 1989. An Integrated rural health project in Saradidi,

Kenya. Social Science and Medicine, 8: 1063-I 071

17
Decision Making

The moving force seems to be the community itself. The Saradidi community is involved
in the decision making processes regarding all the activities taking place in Saradidi. For
example, The community is informed about the type and duration of research project in
the SRDP. If a rcscarchcr fails to explain the work to be undertaken in lay language, that
may be the end of the research, and at least two projects were never completed.

Programme support from the community has included voluntary leadership groups with
the power to hire and fire project workers for any reasons ranging from perceived lack of
commitment to the ethos of SRDP to mismanagement of project activities and resources.
Existing (government) administrative leaders have effectively been part of project
management. Other leaders have come from among church groups and ordinary village
folks.

Lessons Learned

All the external inputs had their side-effects on programme operation and management as
each donor imposed peculiar demands impinging on overall programme activities and
thus on goal attainment. The FPIA, for example, pushed for intensified promotion of
family planning, using the number of new acceptors, as the measure of programme
success. Awareness created in the process was not considered an imbecile measure.

Funding from donors requires increasing details of data to justify further support. Quite
inadvertently, the purpose and attention of the project was often diverted considerably.
For example, reporting on utilization of funds (project implementation) accounted for a
disproportionate effort of the director. Yet this is a major requirement of many donors as
a condition for further funding.

From 1980 to 1983 there was a large turn over of volunteers whose interests and
influence were generally supportive of the SRDP concept. The volunteers brought their
own peculiar ideas which were strategic. Sometimes the volunteers were like unguided
missiles attempting to bulldoze the community to certain preconceived directions.

Tensions between the community and the volunteers were not uncommon during 1980 to
1983. The project director’s inability to harness the interests of the volunteers and the
researchers did not help reduce the tensions.

Among the most noticeable failures was the spring protection schemes. Saradidi suffers
from a chronic water shortage and cor+m ination which partly explains the prevalence of
waterborne diseases. However, ‘appropriate’ water t_;chnology experts received little
community support Some pr-otccted springs mysteriously dried up or were inadvertently
blocked. Predictably, the community developed little confidence in the experts. It had

18
been assumed that the mere shortage of clean water would be a rallying point for spring
protection in the villages. As it turned out, there was little enthusiasm.

It had not been foreseen that a protected spring would be thought to be a potential benefit
to any one village as it previously served the villages around it. Parenthetically, on their
part, the technical experts diligently relied on their technical know-how and left the
community unconvinced. In this case the technology was apparently appropriate, but
lacked the necessary mark of approval of the benefiting community.

In terms of PHC development the lesson that emerges from the SRDP experience on
project formulation was that a viable PHC project must include the community as a
central entity. In the formulation of PHC project and programmes, the lesson is that the
project must be within the context of communities expected to benefit or served.

Mobilization for Nutrition in Tanzania (The Iringa Nutrition Project)

The project was lunched in 1983 with an aim at understanding and addressing the
problem of malnutrition in Tanzania. The major intervention components included food
production and conservation, feeding practices of young children, day care centres, water
supply and sanitation, and support to household and village institutions in relation to the
above. The project followed Lhc triple ‘A’ (Asscss~ncnl, Analysis, Aclion) apprc)ach. ‘I‘he
lringa approach was a combination of goal-oriented, normative, top-down advocacy and
social mobilization and empowerment of people for bottom-up actions. The programme
resulted in improvement of the nutritional status of children and ensured community
participation in the activities.”

Goal

The project aimed at reducing infant and young child mortality, ensuring better child
growth and development and improving maternal nutrition.

Implementation and Strategies

The INP utilized existing administrative structures, starting at the regional level and
involving districts, divisions, wards, and most peripherally, 168 villages. The activities
were initiated and coordinated by the village Health Committees, answerable to the
village council, comprising the village Chairman, Secretary and other individuals chosen
by the Council. Full time government administrators were entrusted with the
responsibility of coordinating and ensuring access of these nutrition committees to the
various sectoral resources, both human and financiA, such as extension workers from the

” Jonsson U., Ljungqvist B. and Yambi 0. 1993. Mobilization for nutrition in Tanzania. In Rohde
J., Chatterjee M. , Morley D (eds), Reaching Healfh forA//, Oxford University Press, Delhi, pp.185
211

19
departments of health, agriculture, community development and education. A National
Steering Committee with representatives from the prime minister’s office, the line
ministries, the nutrition centre, UNICEF and WHO provided overall policy guidance.
These functions were eventually delegated to the regional steering committee at Iringa
and later to other regions which took up this approach for development.

The proposed programme had 11 projects, and 38 sub-projects including support to the
health sector, environmental health-hazard control, education and training, child care and
development, technology development support, household food security, food
preparation, communications, monitoring and evaluation, and research and management.
A 220-page plan of operations outlined all the activities in detail. The central piece of the
programme was community-based growth monitoring in which each village would
conduct a quarterly nutrition assessment day. Political support ensured large levels of
participation in the measurement of children’s nutritional status. There was also high
participation in the related analysis of the findings and community discussion of actions
to be taken to improve nutrition as well as to resolve other problems identified. The
‘Triple A cycle’ -- Assessment, Analy\is and _4ction became the hallmark of the INP. It
described the procedure followed at each level: housci-iold. village, ward and district in
dealing with the issues emerging from the three monthly assessment procedure. The
community actions that emerged ranged from capital-intensive infrastructure projects,
such as piped water or construction of health centres to income-generating activities,
establishment of childcare centres and a host of agricultural, animal husbandry and
environmental interventions.

Social Mobilization

High-level political support and action was the hallmark of the programme from the
outset. The INP was launched in December 1983 by the then Prime Minister who spoke
for nearly one hour to a gathering of thousands of people in a stadium in Iringa town. The
inauguration was itself a major act of social mobilization. It was followed by mass
meetings in each of the INP villages facilitated by trained workers, and the screening of a
carefully made film “The Hidden Hunger. ” The film highlighted the wide prevalence of
invisible or hidden forms of malnutrition and the major underlying causes. It was shown
in each of the 168 villages before the first scheduled ‘health day’. The health day was a
regular quarterly occasion during which all children were weighed, immunizations
provided and ORT demonstrated. On this day, extension workers described and discussed
alternative intervention responses lo t,,.,
ho village-wide
_ growth monitoring results. More
than 1000 leaders were trained, and politicians from the village to regional levels were
taught how to analyze the causes of malnutrition and the options for action at their levels.
The “Triple A” approach was emphasized in the training. Following the initial village
orientation, two volunteers were trained as temporary village health workers (VHW).
They learned how to conduct growth monitoring and record growth information.

After the crash training programmes in each village and the initiation of health activities.
village day care centres were established.

20
Feedback to the Community

The community-based growth monitoring activity served to focus attention on the

nutritional status of children. It also provided villagers with a tool to examine their
nutritional problems. It was also the basis for an information system which was used for
motivating and activating higher levels of the Government to take action at the
community level. The system was primarily motivational. Programme activities were
measured in terms of their nutritional impact rather than simply as ‘inputs’.

The village weighing days, often held monthly, were attended not only by all children
and their mothers but also weights were charted and subsequent home visits were made to
each undernourished child. Group sessions on health and nutrition education were held
and mass services, such as immunization, demonstration of ORT, treatment of malarial
fever, were provided by health workers from nearby dispensaries. A simple one-page
report subbed quarterly- to higher levels described the weight-for-age of all participating
children and reported on any deaths occurring in the pervious quarter along with the
presumed cause. Of even greater importance was the written record of actions being taken
at the village level. The minutes of village meetings decried requirements from
government sectors at higher levels. They represented at on-going dialogue from the
village to liighcr Icvels of all participating niinistrics.

Achievements

The INP was evaluated in mid-1988 by a team of experts. Severe malnutrition had
declined from 5 per cent to below 2 percent, and overall under nutrition had declined
from 50 percent to about 37 percent. A fall was seen in severe malnutrition in all
expansion areas. Process assessment showed that 85 percent of mothers fully understood
the growth chart and were adhering to suggested child care practices such as frequent
feeding.

Special Feature

The uniqueness of Iringa as a nutrition improvement effort lied in the development of the
process rather than in any particular element of the project. It was an understanding of the
Triple A process that will determine how the project’s success can be transferred to other
situations and conditions. The growth monitoring activity is ultimately a communication
strategy operating at all levels from household through village and upward to the region.
It facilitated communication between mothers, with village leaders and other personnel,
government resource persons and political leaders. The attention to malnutrition and
health of children, enabled by the INP information system, brought all levels into a
common communication relating to these issues.

The attention of the INP to the measurement of nutritional status and the repeated
assessment and charting of growth started as a strategy to mobilizing communities. Thus,

21
third-degree malnutrition was characterized as a condition next to death. Regular
weighing of each child was possible, and villages could see progress even if they could
not measure fall in the rates of mortality. The visualization of growth on the weight card
was a tangible means for mothers to see the effect of their own actions. The fact that
villages could organize and sustain this monitoring activity on a regular basis was an
indication of the independence this project engendered and a key element of its success.

Financing

Expansion of the INP experience began as early as 1985 with modest funds from
UNICEF and donations from abroad. Under the guidance of the National Coordinating
Committee for Child Survival Progrmmes and the Planning Commission, additional
regions in Tanzania were encouraged to formulate programmes. Resources were
mobilized from the National Treasury and from abroad. The World Bank, EEC, IFAD,
NORAD, SIDA, and ODA had supported the expansion of the programme. It was
expected that the entire Republic of Tanzania will have adopted the ‘Iringa Approach’ by
199596.

Community Participation

Almost all important aspects of the INP were characterized by a high degree of
participation. A study that compared four well-known nutrition programmes on the basis
of eight programme elements that would benefit from community participation found that
Iringa scored the highest overall and in each element separately .

The application of the “Triple A” strategy was identified as the key to the good progress
of the INP. This approach was fundamentally participatory and empowering for
households and communities. It resulted in a greater mobilization of local resources. For
example, the establishment of centres to care for young children, financed by the
communities, was the result of such participation. Another tool was growth monitoring
which was also a source of information used in community level discussions and
decisions. Thus, growth monitoring played a role in social mobilization and enhanced
participation. This gradually created an articulated demand by the communities at the
higher administrative levels of society i.e. districts and region.

The participation that the “Triple A” strategy invoked, in fact, went beyond the
involvement of communities in project implementation. It created an environment in
which outsiders were accepted and allowed to participate in programmes designed and
owned by the communities. This was somewhat different from which usually prevailed,
where the community is expected to participate in activities designed and directed from
outside.

22
Community Empowerment and Self-reliance

Local level project management was achieved during the expansion phase of the project.
Individual situation analyses were done and the programme was expanded to cover the
entire Iringa region, with some 450 new villages added to the original 168. The addition
of 150,000 children to the programme was managed almost entirely by the existing staff
with very little outside support. Recruitment of health workers, establishment of the
village-based monitoring system and provision of some key health services, such as
immunization and ORT, were undertaken.

It was not clear how much self-reliant the community members became in relation to
maintaining activities to improve health and what might have happened after withdrawal
of the project activities. It was claimed that community ownership was never seen to be
in conflict with the Government. A deliberate effort was made to strengthen and
establish linkages between the communities and the Government. Just as communities
need to feel ownership of community-level interventions, the government needs to feel
ownership of the community experiment. This occurred at Iringa, facilitating expansion,
replication, and sustainability.

Community Involvement in Health Development: Caranavi District,

Bolivia

This was an experimental project carried out in the district of Caranavi from 1986. The
project was based on the assumptions that the existing professional staff at the district
level was not enough to extend health care within the district and that the only way to
have this achieved would be through involvement of local people in the health service.
The approach to community participation was seen in terms of local-level collaboration
with the existing services and of the assumption by local communities of a greater
responsibility for their own health care. The project began with external funding and did
not sustain. Nevertheless, the experiment provided invaluable experience for those who
are interested in community participation.”

Project Philosophy and Implementation

The pro,ject was conceptually based on a new approach to health announced in 1983 and
was carried out by the district health authorities with external financial support. The new
approach argued for the need of a more effective regionalization of existing health
scrviccs, with health priorities based upon primary health cart, and mother-child and
environmental health. It was pointed out that Bolivia had an enormous richness and
tradition of popular organizations (e.g. workers’ and peasants’ unions, and neighbourhood

” Oakley, P. 1991. Community involvement in health development, Carnavi district. Bolivia. In

Oklay, P., et a/. eds. Projects wth People: The practice ofparkipafion ln rural development.
Oxford & IBM publishing Co. Pvt. Limited, Geneva, pp. 145157

23
and community associations) and that these organizations could be involved in future
health development to achieve community participation. The approach laid great
emphasis upon the concept of participation and proposed to structure organizations which
would allow effective people’s participation in health development. To fulfill this a set of
People’s Health Committees (PHCT) was formed at various levels of health services with
a central committee at the national level.

In the first instance, this new health strategy established the following two basic priorities
as a means of giving some immediate direction to future health development:

(a) an immediate programme of massive popular mobilization for vaccination campaigns,

e.g. polio. Nationwide campaigns were launched and used as the means by which people
could be brought into health activities;

(b) the structuring of people’s participation and the setting up of a nationwide structure
within the health service which would facilitate people’s participation. The basis of this
was the People’s Health Committee.

In terms of the implementation of the above approach, there were two main lines of
thought :

l to strengthen the existing health structure, with emphasis upon its regionalization
and more effective coordination among its different levels and departments; and

0 to strengthen the means of people’s participation.

Management

The central objective was co-management of the health service between health
professionals and local people via a structure of popular organization. The
conceptualization envisaged two parallel, collaborative and mutually supportive
structures which would lead to a far wider people’s involvement and mobilization of local
resources in support of health development. It would not be a competitive structure, but
both sides would have an agreed upon role to play.

Structure of People’s Participation in the Caranavi Health District

To achieve community participation, PHCT were formed at various levels. The PHCTS
were supposed to perform the following functions :

0 strengthen existing communal structures through planned development

activities;

l develop a greater local critical consciousness of health issues;

24
 l seek to improve the living conditions of local people and defend their
interests; and

l support existing health services so that they function better.

The PHCT was regarded as essentially a people’s organization, which would seek to
involve people locally and would tackle local health problems. It was to be a
representative and democratic body which would stress the value of communal actions
and the joining of forces to tackle local health problems.

In reality, the PHCT in Caranavi Health District was a more complex structure than the
people’s Health Center, and little really was known about how well or in what ways it
functioned. It would appear that there was no common pattern either of the tasks which
PHCTs undertook nor of how they did function. PHCTs appear to range from the active
to the sporadic and to the dormant and inactive. PHCTs in or nearer the towns or larger
settlements were more active, while in many instances, little was known about what was
happening in some of the more isolated settlements. In this respect, the health auxiliary of
the health service system was a key figure; he or she had to get the PHCT going and the .
energies and the level of involvement of the health auxiliary had a direct influence upon
the PHCTs in any health sector.

The key to the implementation of the Caranavi health development experiment was the
People’s Health Agent (PI-IA) The PHA was a locally based health worker, selected by
the community, trained by the District Health Service, equipped with the basic means to
function and expected to serve as the community- based link between the Health Service
and the people. The PHA was the symbol of participation, the democratization of the
health scrvicc and the mca11s by which people on a Tar wider basis could be broughl
within the ambit of health care, In terms of selection, it was suggested that a PHA should
be literate, preferably young and with initiative, be willing to ‘serve the community’ and
reside within it. In the earlier literature on Ihc new health strategy, the basic functions of
the PHA were seen as follows:

l promote the participation of the community in health activities;

l treat basic illnesses, with priority to mothers and children;

l seek to prevent diseases by means of health education;

. implement the district’s health plans;

l maintain a supply of basic drugs and health equipment in the PHCs;

. undertake a local census;

 l complete a monthly report on births and deaths.

Problems

The performances of PHAs in the health areas were subject to considerable variation and
fluctuation. In each of the health areas, a hard core of original PHAs probably still exists,
and these tend to be the more active ones. A widespread network of PHAs was set up
quickly in 1986-87, but nobody had any substantial information as to what extent and
how well it was still functioning. In discussions concerning problems associated with the
performance of the PHAs, the following were mentioned:

. a continual lack of basic drugs, without which the PHA was unable to function
or maintain credibility in the community;

l irregular or sporadic contact between health service staff and the PHA, which
often results in a PHA simply ceasing to function;

l PHAs were often not linked to traditional medical care within the community
a11d LllUSlacked support;

. some PHAs were closely linked to political structures within the community
and selected on that basis;

l PHAs were usually literate and Spanish-speaking, while in the settlements,

illiteracy was high and most people speak Aymara or Quechua;

l PHAs were trained as the last link in a vertical health service structure;
inevitably they transmit this vertical authority to the villages in the way they
deal with local people.

Critical Assessment

Given the general paucity of resources for district health development in Bolivia, the
Caranavi experiment would never have got off the ground without support from the Pan-
American Health Organization. This support was crucial, but unfortunately it has not
been sustained. Caranavi showed, however, that with an initial external impetus and
concentration of resources, experiments in health dev-elopment could take hold and could
quite quickly have a structural impact. At the time of this experiment, the district health
service was the only development service which potentially reached even the most
isolated settlements, and clearly it helped both to break their isolation and to integrate
them into development activities.

Caranavi similarly demonstrated the clear link between district-level structures, which
were seeking to promote people’s involvement, and health service decentralization and

26
local autonomy. People’s involvement must be built from the base upwards; it was not
enough merely to proclaim it at the national level. In order to do this effectively at the
district level, there must be some degree of local autonomy, control at the district level
over health resources: and a district health service budget. In fact Caranavi had none of
these facilities. Perhaps, the central problem here was the fact that the Caranavi
experiment did not originate in the La Paz Health Unit ; it was largely isolated initiative
and had no real institutional base in the Bolivian Health Service. Whatever the
explanation, however, the experiment does suggest that the building of local level
structures and the development of a health service in which pe.ople have a major role can
best occur when district health services have some degree of local autonomy and when a
district-based health budget exists. It is impossible for the health unit to develop and
build upon local initiatives; this can only be done at the district level.

It is difficult to be sure what the notion of “participation” meant in the context of the
Caranavi health experiment. The Health District and the experiment were born out of an
ideological reappraisal of health and health development in Bolivia; but the actual
practice had been far less radical. The notion of ” participation” which emerged in
Caranavi had largely been dictated by the availability of resources.

Finally, a lot has been learned about people’s participation and district health services
from Caranavi . By examining the three-year period and looking at the way in which
participation developed, four stages can be identified:

1. initial contact : broadening the coverage of the health service;

3
i. active local involvement in specific health activities e.g. vaccination
campaigns;

3. generating a more general interest in health development issues;

3. strengthening of the educational component of participation and development

of more direct involvement in health service organization and management.

‘I’hc pmcticc, of course, was not as clear as the above, but certainly thcrc wcrc cvidcnce of
these different stages in several health areas. Some localities in Caranavi progressed to
stages 1 and 2, albeit with varying degrees of sustainability. There were some initiatives
aroused stage 3 in 011e or two yxtors. largely built around the training of PI-IA. Stages 1
md 2 \VCI‘C the lcast difficult to xhicvc; stages 3 ;ind 4 demanded more substantial
Sllppc)rt 2nd appropriately 1r3incd staff‘.

27
Comilla Development Model, Bangladesh

The Comilla Development Model was a community development strategy popularly

known as Comilla Approach (CA). This was developed at the then Pakistan Academy for
Rural Development at Comilla, presently known as the Bangladesh Academy for Rural
Development (BARD). The approach incorporated a two-tier system with cooperatives at
the village level and a Thana Training and Development Centre (TTDC) as the focal
point at the thana level. The approach was considered effective in its pilot phase and was
replicated nationwide later through government systems with limited success.‘2

Goals

The major goals of the project included the following:

. make the villagers understand their problems best so that the village lcvcl
workers (VLW) can learn from them and could explain the new approach;

b make the villagers capable of taking initiative for improving their

condition through individual and cooperative action;

. create a capital followed by the provision for training and technical inputs,
with an active participation of the villagers achieving the developmental
process;

l encourage the villagers to organize themselves into cooperative groups;

l focus attention of income generating and di: ectly productive activities

with demonstration effects aiming at standards of living;

l provide technical and agricultural extension services;

l increase agriculture production and income-generating activities through

provision of credit and technical inputs. training and extension services
and improve marketing mechanism;

l develop Rural Works Programme (RWP) and Thana Irrigation Programme

(‘III’) in creating physical infrastructure and income generation;

0 reduce costs and create managerial skills emphasizing local planning and
participation of the local population;

” Chowdhury A N 1990 Cornlila development model. In A N. Chowdhury, Let Grass RXJ~.S

Speak, University Press LImIted Dhaka

28
 0 set up women’s programme and family planning project and to start one-
teacher village school.

Activities

A range of activities were included in the project. These were:

l increasing agricultural production and income-generating activities through

provision’of credit and technical inputs, training and extension services, and
improved marketing mechanism;

a rural works programme including thana irrigation programme to create

physical infrastructure and income generation;

l women’s programme and family planning; and

l establishment of one-teacher schools.

Strategy

The implementation of the CA began with conducting meetings with the villagers at
strategic geographical points to ensure maximum attendance to motivate the villagers to
undertake changes, learn how to implement new ideas, Subsequently, villagers were
brought to the academy for orientation and training. The village-level workers also lived
in the villages to break the traditional socioeconomic barriers. The field off&x-s were
trained to enter into a ‘friendly partnership’ with the villagers’. The officers wished to be
the helpers rather than administrators. The keynotes of this approach were collaboration
and teamwork. Eventually, the villagers were encouraged to organize themselves into
cooperative groups to start saving. Technical inputs for agricultural extension and credits
were channelled through the cooperatives either to the group or to the individuals.

The villagers were the decision makers. Efforts were made to provide the villagers with
institutional framework to make credit and other resource accessible. The villagers were
expected to participate themselves in order to make the best use of the services offered.
The project staff worked with the villagers through collaboration in the teamwork and
were accountable to the representatives of the people in the local government bodies.

Organization

The village cooperative societies were designed to achieve the development of economic
and functional efficiency. Their primary purpose was to remove agricultural production
constraints and to diffuse modern technology. The model was based on primary
cooperatives at village level working with a Thana Training and Development Centre
with a well-built institutionized infrastructure of Thana Central Cooperative Association.

29
Achievements

The programme demonstrated utmost potential for rural development. Some of the
cooperatives made significant beneficial impact on the lives of the beneficiaries.
Impressed by its success in Comilla, the model was replicated nationally as Integrated
Rural Development Programme and later as Bangladesh Rural Development Board in the
seventies. .

Replication

The Bangladesh Rural Development Board (BRDB) implemented the Comilla Model of
cooperatives nationally for the landless as BSS and the Mohilla Samiti for women as
MSS. The BSS and MSS were set up during the middle of the Second Five-year Plan
(SFYP) in 1983. Being recent institutions, the results of these schemes cannot be fully
assessed. They are expected to provide support and services in terms of skill
development, credit and input supply to the members for employment and income-
generating activities in the aIlied farm and non-farm sectors.

About 77,000 BSS and 57,860 MSS have been organized with about 225,000 and
220,000 members respectively. At present, they are federated with the Upazila Central
Cooperative Association(UCCA). Twenty non-farm income-generating activities have
been selected for credit channelling to the distressed and landless groups. They are : pond
fisheries, rice husking, goat rearing poultry raising, cattle fattening, rickshaw and
rickshaw van, cane and bamboo works, cottage industry, bee-keeping, weaving, oil ghani,
muri making, mat making, small trade, carpentry, pottery, kitchen gardening, sewing and
garment making, livestock and milk production and mechanics.

The replication of the Comilla Model as Integrated Rural Development Programme

(IRDP), later I3angladcsh Rural Dcvclopment Board (BRDB), in the seventies started
with a setback. The new Govern:nent offered large scale highly subsidized agricultural
inputs e.g. tubewells through Bangladesh Agricultural Development Corporation
(BADC) without proper standards of selection. Needless to say, the agricultural assets
were acquired by influential members of the cooperatives and local leaders. On paper, aI
irrigation fund or cooperative was set up which soon decided that the loans for the
subsidized pumps riced not bc rcturncd, and then trcatccl the grants as free gifts Fllnds
I‘or r-cplt- LYCIC i10I I’orthcolllillg: ~licrcli~rc, 50 pc~-ccnL 01‘ the tubcwclls soon I‘ell inlo
disuse due to iack of repair.

Furthermore, attempts on a national scale have never been made by a single agency to
replicate the model in its entirety. Lacking a coordinated approach, the two-tier
cooperative system, the Thana Training Development Centre, the Rural Works
Programme (RWP) and ‘Thana Irrigation Programme (TIP), pursued by the Ministry of
Local Government, Rural Development and Cooperatives (MLGRDC), and without
corresponding progmmmes in education and integrated exrension services, the CM lost

30
much of its originality. The hopes raised by the RWP, the TIP and TTDC had not been
fulfilled in later years either.

In spite of the best of intentions, BRDB provided more benefit to the land owners. The
landless and marginal farmers who constituted about half of the rural population
remained outside the mainstream of economic activities.

Sustainabtity

CA was not in a position to lunch massive projects for the rural poor and landless
although it was an agricultural growth-oriented programme. The establishment of Small
Farmers Development Schemes and only a few cooperatives like Deedur had positive
effects on small farmers and day labourers, including rickshaw pullers. Out of 400
cooperatives, only 61 were functioning. After 20 years most of the cooperatives failed to
conduct weekly meetings, training, and follow-up. The lack of regular BARD supervision
procedures had led to misuse of cooperatives and manipulation of the poorer members.
‘1‘1~dishonesty of‘ the cooperative members resulted in misuse of the cooperatives for
procuring individual benefits.

Despite the above the concept of cooperatives developed through the Comilla Approach
has resulted in many successful cooperative initiatives in the country. Most often
succeeded were the ones with strong local initiatives and leadership which could negate
the discouragement induced by large-scale extension under the governmental
bureaucracy.

Chakaria Community Health Project (CCHP), Bangladesh

The Chakaria Community Health Project of the International Centre for Diarrhoeal
Disease Research, Bangladesh (ICDDR,B), has started in 1994 in Chakaria thana under
Cox’s Bazar district. I3The major objectives of the project have been to discover a
strategy to ensure community participation in health matters and to assess the impact of
such initiatives. The project has been trying to activate the existing indigenous village-
based organizations (referred to as self-help organizations - SHO) to take initiatives for
the improvement of health. Participatory research methods have been extensively used in
carrying out the project activities. In its two years, the project made significant progress
toward fulfilling its major objectives. The future challenges are to find ways to keep the
initiatives of the village-based organizations sustained with minimum or no input from
the project.

” Bhulya, A. 1996. Rethinking community participation. I :Prospects of health initiatives by

Indigenous self-help organizations in rural Bangladesh. Paper presented at the Fifth Annual
Scientific Conference (ASCON V), International Centre for Diarrhoeal Disease Research,
Bangladesh, Dhaka

31
Goal

l develop a strategy to ensure community participation in health matters and to improve

health of the community members;

. measure the impact of the interventions on health.

Strategy _

The project adopted the following strategies in implementing its activities.

l work only through indigenous village-based local organizations and bring

health on their agenda;

l activate them to take health initiatives with own resources;

l promote preventive measures;

l provide technical assistance in health matters and organizational development;

. promote utilization of existing health facilities;

. utilize participatory methods in every aspect of project implementation such

that community takes leadership and remain in control.

Financing

The project has been funded externally. However, the community initiatives have been
funded by the village-based organizations with technical support from the project.

Achievements

During the first six months of the project, members of the staff were able to establish a
confident relationship with the villagers. In the beginning, the female community
organizers faced resistance from the villagers even to meet women which was
significantly reduced after three to four months, and work could be carried out.

Rcprcscntativcs ol‘the scll~l~clp org:animlions in health orientation sessions

parlicipalcd
organized jointly by project staff and the self-help organizations. Action plans were
developed’by the SHOsto impart health education to the community members by
volunteers both at the community and educational institutions.

So far, over 1000 volunteers ( male female and student) have been nominated by the
SHOs and neighbourhood clusters ( in cast of female volunteers ). Most of them have

32
participated in training programmes organized by the project without receiving any
material or cash incentives from the project. The school health volunteers communicate
health messages to fellow students once a week for half an hour. The students also take
the messages to their homes and share with other family members and immediate
neighbours.

The male village health volunteers disseminate health messages in mosques during Friday
prayers and in informal gatherings at tea stalls, and at other informal meeting places. The
female volunteers disseminate health messages to women in nearby households.

In three villages, the self-help organizations have implemented, in collaboration with the
government health authorities, a programme to control malaria by using impregnated
mosquito bed nets. Despite discouragement by the project about curative services, the
SHOs have established six village health posts with community resources. Village heath
care providers nominated by the SHOs and trained by the Government have been
providing services in these health posts. Moreover, the government outreach services
have started to take place in some of the village health posts on request from the SHOs.

Steps in Implementation

The following steps were involved in implementing the project activities:

1. Confidence relation building with the community through PRA;

2. Assessment of health problems through focus group discussion and individual

discussion with key persons;

3. Arrange people’s participatory planning sessions to identify problems,

possible solutions, prepare action plan, implement and monitor the activities.

Organization of the Project

The project started with a team of six community organizes ( 3 female and 3 male >, two
self-help trainers, two applied social researchers, and a field team leader under the overall
direction of a social scientist with technical assistance from an expatriate anthropologist
throughout, a trainer at the beginning and a resident anthropologist at a later stage.

After a year of operation, one male and female public health physician and two
paramedics have been added to mainly ensure the relevance and quality of health
messages and to provide technical assistance in identifying effective solutions for solving
prevalent health problems.

The community organizers have been responsible for establishing links with self-help
organizations and community and for mobilizing them. The community health workers
have been maintaining contact with the SHOs and gradually carrying out the work once

33
done by the community organizers. The applied social researchers were engaged in
monitoring, evaluation, and providing feedback to the programme. The Field Team
Leader is responsible for overall supervision in the field and maintaining links with
Government and NGO activities in the locality.

Problems Encountered

While implementing the project, the follo~.~~ingproblems were faced:

l Relief mentality of the community members;

l Demand for curative service among the villagers;

l Traditional attitude of the villagers about women - unwilling to see women

moving around;

l Anti-NGO sentiment of the villagers;

l Hatred against female NGO workers riding motor cycle.

Other problems included steering of the project personnel centering the project
philosophy, maintaining the project philosophy in the face of the current trend of
development with external resources, and responding to the needs of the community
without creating a dependency relation between the community and the project.

Special Feature

One of the important strategies adopted in this project was to augment the agenda of the
existing self-help organizations and activate them to take health initiatives. The project
has been trying to participate in the endeavours taken by the SHOs rather than inviting
villagers to participate in activities designed, implemented and managed by outside
agencies,. The processes of relation building, needs assessment, health orientation,
planning and implementation, were carried out in a participatory manner resulting in
community involvement right from the beginning.

Sustainability

It is too early to comment on the prospect of sustainability of the initiatives taken by the
SHOs. IHowever, it is somewhat clear that the future continuation of the activities will
largely depend on the sustainability of the village health posts in some form or the other.

34
Conclusion

It is evident from the literature review that various models have been utilized
internationally to increase community participation and thereby long-term sustainability
of project innovations. The eight most relevant projects reviewed above were from India,
Kenya, Tanzania, Indonesia, Bolivia, and Bangladesh. The sectors involved in the
development activities ranged from rural health to agricultural cooperatives. All had
relevant national policies. A few attempted an urban focus on social mobilization.

Essentially, three models emerged: a small NGO working with a limited number of
communities on a moderate range of complex issues (rural health and development
activities); an international organization collaborating with local governments on a
limited range of activities (e.g. nutrition); and a large public sector activity working on a
complex set of issues (e.g. cooperatives and rural financing).

The nature of and opportunities for participation by the community in these projects
ranged from membership in committees created by the projects, provision on voluntary
labour, financial and/or material support to project activities, payment for services
through local direction and management of the development activities. All of the projects
began with initiatives from outside the community, and many were supported either
politically or financially by national governments or donors ranging from local churches
to multilateral UN agencies. Most of the projects documented community-involved
development activities designed by outside experts or extension workers on the basis of
their understanding of local needs. The less successful efforts utilized the community
merely as the instruments of a national development scheme often with a plan to involve
community following a top down approach.

Nevertheless, most successful projects used a process which took advantage of local
structures, facilitated the utilization of local resources, either within the community or
local NGOs and employed the systematic use of information for determining directions.
This information often included community needs and interests as well as information on
the feasibility of achieving benefits for the community from a particular development
activity. One project (the Iringa Nutrition Project in Tanzania) described the process as a
“triple A” system, as the decisions on local investments were made through local
Assessment, participatory Analysis, and community Action.

Most of the projects had a long-term focus, that is generally over ten years and some as
many as twenty years. Nevertheless, the community participation efforts documented in
the litcmturc dcscl-ibcd cxpcricnccs gained during the project activities, and rarely talked
about sustainability after the withdrawal of extra-community support. This is particularly
critical for Bangladesh, where it is expected that the international support will be
diminished with time and community financing efforts must increase.

3.5
An exception was a project in India (e.g. the Comprehensive Rural Health Project in
Jamkhed, Ahmednagar District, Maharastra State), which began withdrawing support
after 17 years as many of the community organizations formed have become self-reliant.
In case of the Kamataka project in India, the Family Planning Association of India also
was able to reduce its contribution to local education and development activities within a
five-year time frame by identifying other local NGOs who could be helpful in either
keeping the project going or in expanding its range of activities, and by increasing the
contribution of the communities’ own resources. Nevertheless, it is unclear how well the
activities are being carried out and how long these will sustain. The question of
replication is also important and the Jamkhed project also did not indicate any strategy
for replication.

Another relevant project is the ongoing Chakaria Community Health Project (CCHP) of
ICCDR,B. This project is an example of the second model, that is an international
organization collaborating with village-based indigenous organizations, referred to as
self-help organization (SHO) to promote health, especially preventive measures. The
approach has been participatory implying that the needs assessment, identification of
solutions, planning and implementation of actions, and monitoring of the impact, have
been done with the members of the indigenous organizations. The use of participatory
research methodologies have been made extensively. The project in its third year could
mobilize the community members and local resources to take initiatives for the
improvement of’health without material support from the project. Although the
community enthusiasm and participation are apparent, long-term scenario is unclear.

One of the latest developments in the CCHP is the establishment of village health post
(VHP) by the SHOs. Currently, village health care providers, nominated by the SHOs and
trained by the government health authorities, have been providing free services in the
village health posts on a part-time basis. SHOs have also been establishing link with the
government health and family planning workers to provide services on the days of the
monthly VHP sessions. With reference to the sustainability of the VHPs one way can be
establishment of link with the government services, however, their growth will be
dependent on the level of government supports and may suffer from similar constraints as
that in the government facilities. It is obvious that the development of the VHPs will need
financial and technical resources and quahty of relevant services. Thus, a mechanism has
to be found to generate resources for it is very likely that the future of these community
initiatives can largely depend on their development in terms of quality and scope.

The replication of successful experiences in community participation is another problem

area. The replication of the Comilla development model nationally through the
government machinery in Bangladesh was, in fact, a major failure. In Bolivia, the
community participation through peoples health committees to work side by side with the
government system did not work. Thus in the context of community participation, two
major challenges are: development of a model and then the possibility of its replication.
Development of a model may be easier than replication because in most cases nationwide
replication demands use of government system which in the past did not work in many
settings of the world. The less explored, however, have been the utilization of private
sectors.

In conclusion, while community participation in any development activities -- be it health

and family planning or any other sector is highly desirable. There are really a lack of
appropriate models to ensure, replicate and sustain it. The prospect lies in using existing
social capital as much as possible to ensure community participation and ingenuity in
generating resources from the system for growth and expansion, perhaps through some
kind of balance between the public and the private sectors.

37
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