Community Health(1)-Community Health Study Pack

7/27/2019 Community Health(1)-Community Health Study Pack

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REF LECTI ON AN D LEA RNING FOR GOOD DEVEL OPMEN T PRA CTICE

T E A R F U N D CA S E S T U D Y SE R I E S

CommunityHealthDevelopment

S TU D Y P A C K FO R CO MM U NI T Y DE V EL O P ME NT WO R K ER S

AUTHOR: Tine Jaeger- Technical Response Team

EDITOR: Kate Bristow- Technical Response Team

ACKNOWLEDGEMENTS

We would like to thank Dr Kiran Martin, director of ASHA, Drs Raj and Mabelle Arole,Directors of Jamked, Esther Surrage, Asia desk officer, Christian Outreach forpermitting Tearfund to represent their programmes in this manner. We wouldalso like to acknowledge the contributions and comments of Dr Simon Batchelor,community development consultant and Mrs Muriel Chowdhury, communityhealth consultant.

February 1999


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Contents

Illustrations Index page 3

Section OneWho is this case study for? page 5

How to use the pack page 6

What is community health development? - An overview pages 7-11

Section Two

ABCD Overview of the programme page 13

Clear vision, objectives and activities - principle 1 page 14Partnership with donors -principle 13 page 15

ASHA Overview of the programme pages 16-17

Community ownership -principle 3 page 18Skilled leadership -principle 7 page 19Appropriate activities - principle 8 pages 20-21Partnership with local and national government - principle 11 page 22Partnership with national/international non-government andcommunity organisations- principle 12 page 23

JAMKHED Overview of the programme pages 24-25

Focus on the poor -principle 2 pages 26-27Sharing of skills to support the development of communities - principle 4 page 28Resource mobilisation -principle 5 page 29Skilled, committed and motivated facilitators -principle 6 page 30Efficient monitoring mechanisms and evaluation framework - principle 9 page 31Secondary health referral -principle 10 page 32

CONCLUSION page 33

Section Three

Comments on discussion questions pages 35-43

Studying in small groups page 44

Evaluation of non-medical aspects of community health development page 45

Action plans page 46

Guidelines for good practice in community health development pages 47-50

Glossary page 51

Abbreviations page 52

Recommended reading and references page 53


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Illustrations Index

Fig1 What is Community Health Development? page 5

Fig2 Historical time line of community health programmes page 7

Fig3 WHO - range of primary health care activities page 8

Fig4 Deprivation trap page 8

Fig5 Spectrum of community health programmes page 10

Fig6 Diagrammatic representation of community health development page 10

Fig7 Village in Prey Veng page 13

Fig8 Village development committee page 14

Fig9 Ekta Vihar slum colony page 16

Fig10 Dr Kiran Martin with women from Ekta Vihar page 19

Fig11 Community health volunteer with a mother and child page 20

Fig12 Co-operating with the authorities page 22

Fig13 Graph showing decrease in malnutrition rate page 25

Fig14 Graph showing increase in immunisation rate page 25

Fig15 A) Diagrammatic map showing how dalits are not included in Ghodegaon Village page 26

B) Diagrammatic map showing how dalits are now included in Ghodegaon Village page 27

Fig16 Village health worker with village women page 28

Fig17 Villagers working together to conserve water page 29

Fig18 Moses fitting a limb page 30

Fig19 Villager in Ghodegaon explaining their statistics on the board page 31

Fig20 The Two Mules - Everyone benefits when hospitals and primary health page 32

programmes work together

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Section OneS TU D Y P A C K FO R CO MM U NI T Y DE V EL O P ME NT WO R K ER S

Section One

Who is this case study for?

How to use the pack

What is community health development? - An overview


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Community health development (CHD)is an approach to working with communities at grass-root levels. Programmes which implement CHDstart with a clear goal or vision of bringing lasting changes towards full health in peoples lives, especiallythe poorest. This is achieved by strengthening peoples sense of their own value and ability to makechoices and by tackling the root causes of poverty.

Who is this case study pack for?Anybody who is interested in having an opportunity to read, reflect and learn about current thinking intoprinciples of good practice in community health development.

However, the pack has been specifically written with community development and health care workers,who work directly with their communities or run local community programmes in mind.

PurposeTo provide an opportunity for reflection and learning through the study of three programmes thatdemonstrate current good practice in community health development.

This case study pack is a tool for learning and reflection. It does not aim to fully equip the reader toimplement community health development programmes, but section three includes suggestions for

further reading.

Learning Objectives1. Increase understanding and knowledge of the principles of current good community health

development practice.2. Increase understanding and knowledge of how the principles of good practice are applied in

a specific context.3. Enable analysis of how the principles are, or could be, applied in the readers own situation.

The objectives can be achieved by reading the case studies and then actively answering thequestions and taking part in the activities.

Fig1 What is community health development?Crooks Bill, 1999, Tearfund

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How to use the packWe believe everything in thispack is worth reading. You canjust read through the pack and

not bother with the studysections. However, we do, ofcourse, recommend that you dotake time to reflect and learnusing the questions andactivities. We hope that youwill benefit from using the studymaterial in the pack either onyour own or as a group,although we believe that beingable to work with others willincrease your opportunities tolearn (see Studying in small

groups in section three page44).

STEP ONERead the overviewdiscussion of community healthdevelopment (section one pages7 to 11). This will provide therelevant backgroundinformation to the different casestudies and how theydemonstrate good practice incommunity health development.

STEP TWO Before reading theindividual case studies in-depth

you might find it helpful to readquickly through the whole ofSection 2. This will help you togain more from the case studies.A second or even a third readwil l enable you to pick up moredetails than you can on just oneread. It is suggested that Section2 is read together with theGuidelines for good practice incommunity health developmentin section three, pages 47 to 50.

STEP THREERead each study

carefully and begin to think andtake notes about anything thatyou find interesting, new orsimilar to your own experience.

STEP FOURWhen you have readthe individual case study andtaken notes, read the questionsand activities carefully. Dontrush into answering thequestions, take time to thinkand then write down your

thoughts and ideas. If you areworking as a group, spend atleast 5 minutes thinking on your

own before starting to shareand discuss your answers(remember section three willgive you useful advice onstudying in small groups).Sharing your ideas and thoughtswith others often increases yourown understanding and makesideas clearer.

STEP FIVE Before reading thefinal summary and conclusion(page 33) in the pack you mayfind it helpful to write down

your own summary of what youhave learnt either on your ownor as a group.

STEP SIXRead the finalsummary and conclusion (page33) and compare it to your ownideas about community healthdevelopment now that you havefinished the studies. Once youhave reached this stage youmight want to begin to thinkabout a plan for putting some orall of these principles into

practice in your own situation.There are further questions atthe end of this section thatshould help guide you in this(See Action Plans in sectionthree page 46.) We have alsosuggested some other activitiesthat will provide furtheropportunity for reflection.

STEP SEVENThe supportmaterial in section three calledcomments on discussion

questions, pages 35 to 43, isinformation that adds to thecase studies. The authors havegiven their commentsconcerning the questionsaccompanying the individualcase studies. To gain full benefitfrom the pack, we suggest youread this section after you havecompleted all the case studiesand study sections.

Finally, we hope you will enjoy this case study pack. Tearfund has produced two other similar studypacks concerning principles of good practice in HIV/AIDS and Child Development.

STEP ONE

Read overviewin Section One

STEP TWO

Read all SectionTwo once

STEP THREE

Think & takenotes oneach study

STEP FOUR

Work togetherto answer thequestions

STEP FIVE

Write downthe main pointsyouve learnt

STEP SIX

Write anaction plan.

Take part in 2more activities

STEP SEVEN

Read and checkyour answers

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What is community health development?QFrom your own experience what do you believe community health development to be?QWhats the difference between health, sickness, medicine, disease & well-being?

Health vs medicine

In some ways CHD is a newapproach and it is certainly verydifferent to much practice incommunity health programmes.The latter tend to focus onpreventive medicine. It isimportant, therefore, todistinguish between medicineand health. Medicine looksprimarily at preserving and

restoring the human body andmind to health. Health,however, is much broader thanjust the absence of disease.It concerns well-being in everyarea of life: physical, mental,emotional, spiritual, economicand social, and recognises thatthey are all inter-related. So, wecan speak not just of healthy

individuals but also of healthycommunities. This distinctioncan be further explored byreading chapters 1-4, especiallypages 13-19, 30-37 and 54-58 inPrimary Health Care - Medicinein its place by John MacDonald.

Origins of community health programmes

Traditionally, community healthprogrammes grew out ofrecognition that hospitals andhighly qualified professionals(for example, doctors) were notthe answer to ill health. In thelast 75 years, life expectancy inthe west has increased by at least20 years. We have seen that thepopulation grew healthier

because of improvements inliving standards throughprovision of better housing,sanitation, clean water and

improved nutrition. All thesewere achieved without thediscovery and use of antibioticsor advanced modern medicaltechnology. Similarly indeveloping countries, up to 90%of poor physical health is due todiarrhoea, chest infections,malnutrition and easilypreventable infectious diseases.

All of these can be dealt withusing low technology solutionssuch as clean water, oral

rehydration solutions, cheapantibiotics and immunisations.

To implement these solutions,community health programmesgenerally train village level healthworkers to undertake a range ofactivities. These services mayinclude growth monitoring,immunisations, midwifery care,

basic first aid using simpletreatments, health education andhouse to house visits to detectillness and refer patients.

Draw a time line showing when different health care activities were started in your programme or onethat you know. What were the objectives for these activities and were they achieved? (e.g., see figure twobelow)

1920

Massimmunisation

campaign

1950

Mother & childhealth mobile

clinics

1970

Training ofTBAs &VHWs

1980

Mission Hospital

Fig2 Time line

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The WHO defined a range of Primary Health Care activities (Figure three):

Problems with the general approach to community healthQWhat do you think the main limitations of community health programmes are ?

Over the years, programmeimplementors have realised thatthere are many problems withthis approach. Firstly, it oftenfails to touch the lives of thepoorest. For example, very poor

women are often unable tobenefit from the services becausethey need to work at clinic times,live too far away, never hearabout them or mistrust the healthworkers.

The programmes generally fail tochallenge the low status given tocertain groups such as womenand the very poor. Furthermore,those who do become involvedin the programme often do so

only on the level of passivelyreceiving services. They learn toobey the system. Subsequentlythey may change some of theirbehaviour, for example by usinga pit latrine, which is helpful in

improving health; however, thecomplex results of povertyremain unaffected leaving peoplestill vulnerable to chronic ill-health. People are caught in adeprivation trap (see figure four

below). This figure is furtherexplained in the book, RuralDevelopment pages 111-114,R. Chambers.

Nutrition

Antenatal Care

Access tosecondary referral

Essential Drugs

Health Education

Immunisation

Clean Water

Sanitation

Fig4deprivation trap from Chambers R,1993, Rural Development, Putting thelast first, Longman, page 112

Fig3

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In recognition that much diseaseis poverty-related, manycommunity health programmeshave added micro-finance

activities with the aim ofimproving economic status,especially of women. Sadly,even if women gain some smallextra financial means, their statusis often unchanged and theyremain marginalised.

It has also been notoriouslydifficult to sustain the mainpractitioners in the programmes:the community health workers.Difficulties include ensuringregular support and skills-upgrading, maintainingmotivation and deciding onremuneration and incentives.The community health workersmay be exploited by decision-makers who see them as a cheapalternative to doctors and

hospitals. Also, these workersmay end up seeing themselves asbelonging more to theprogramme than to their

communities and may adopt asuperior attitude to the othervil lagers.

Another problem is that differenthealth issues are often dividedinto different specialisms. Thisleads to a sectoral approach witha number of separate (vertical)programmes addressing differentissues such as TB, leprosy, AIDS,nutrition, water and sanitation.Often there is very littlecommunication between thedifferent sectors. Sometimesseparate departments are formedin the same location, forexample, one for communityhealth and another fordevelopment. Since healthcovers all aspects of life, this

separation is illogical andunhelpful. Some of the healthindicators that programmes seekto improve, are often not

significantly changed even aftermany years of programmeactivity. For instance, whilecommunity health programmesmay bring significant increases inlevels of immunisation coverageand consequent decreases inmorbidity and mortality fromsuch diseases as measles andpolio, many programmescontinue to report highincidences of diarrhoeal andrespiratory illness even after 10or 20 years of work in thevillages. This is because basicproblems such as poor water andfood supplies and inadequatehousing have not beenaddressed.

A development approach to community healthQWhat does the phrase a development approach mean to you?QList from your own experience the main aspects of this approach

Programme staff have discovered

that, for community healthprogrammes to bring lastingchange in peoples lives, adevelopment approach must beadopted. Amongst other things,this means: time given torelationship-building,communities encouraged toorganise themselves so they havea voice, emphasis placed onbuilding the ability of individualsand the communitys capacity tocare for themselves, and all

people valued and respected.Any initiative is based on thevillagers prioritiesand they areencouraged to find their ownsolutions to issues which theyhave identified as important. Ifpeople are hungry and do nothave good water to drink, theywill not be interested in diseaseprevention. So it is important tostart with the peoples concerns.Development is total change: notjust health in a narrow physicalsense, but social, economic,

moral, environmental and

spiritual. A key feature in

communities taking charge oftheir lives is the formation anddevelopment of a small group ofvillage representatives. Thesemay be womens groups orfarmers clubs or youth groups.It is recognised that individualcommunities may contain manydifferent groupings and, as far aspossible, all should berepresented so that everyone hasthe chance to be heard.

In the words of an Indianvil lager: a good communityhealth programme makessustainability sure. Onceindividual people and the villagewhere they live have got self-respect and control over theirlives, there can be no goingback. In the end, sustainability iswhat people can do forthemselves; project staff were ameans to this end.

This development approach and

all its activities rests on a strong

foundation of Christian values. It

is based on the fact that man ismade in the image of God; everyman, woman and child isvaluable and has potential; as aperson changes within, so he canchange his situation; personaldevelopment is more importantthan economic, anddevelopment of human capacityto care for others is essential.This means, for example, thatpoor people are empowered tobecome healthier and gain

choice and control over theirlives, not in order to dominatebut to co-operate. Inter-dependence will involve peoplebeing able to approach theauthorities in both confidenceand humility. It also means thatproject activities should promoteChristian values. So, forexample, while emphasis isplaced on supporting people intaking initiatives, these activitiesshould not disadvantagevulnerable groups such as

women or children.

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The diagram below (Figure five) describes the spectrum of community health programmes:

Most programmes will fall between the two types represented here. Some programmes are likely to havea strong community health development focus in some aspects of their work while remaining conventionalin others.

Tearfund Community Health Development GuidelinesIf you havent already done so, please read the Community Health Development Guidelines

pages 47 to 50.

The document included in thispack (pages 47 to 50) which iscalled the Guidelines for Good

Practice in Community HealthDevelopment outlines 13 keyprinciples. We believe these arenecessary for community healthdevelopment programmes to beeffective and sustainable. Theguidelines resulted from a periodof research which included a

0review of current literature,visits to other agencies,questionnaire surveys of partners

and consultants and visits toprojects in Latin America andAsia. Because of the importanceof using a development approachin the implementation ofcommunity health, Tearfund hasdecided to speak of CommunityHealth Development . As the key

principles are much inter-related,there is inevitably some overlapof issues. For example,

community organisation appearsin both principle 3, Ownershipby the community and inprinciple 8, Appropriateactivities. Below is adiagrammatic representation ofthe 13 principles (Figure six).

The case studies in this pack outline threecommunity health development programmes.They all happen to be located in Asia because ofthe authors familiarity with this region. However,

there are examples of good practice in otherregions and it is hoped to add further studies fromother areas at a later date. The case studies do notattempt to describe the whole of each project;rather they show a small glimpse of how each onedemonstrates some of the core principles ofcommunity health development and how this hasbrought long-term changes in peoples lives.Likewise the fact that only a few of the principlesare described for each project does not mean thatthe project only demonstrates these and not theothers, but that focus was made on just a fewelements in each case. As two of the projects(ASHA and Jamkhed) are much older than thethird, ABCD, rather more of the principles arecovered by the first two.

Community health development

Goal: self-reliant healthycommunities

Focus: community organisation Agenda set by community Activities vary according to the

situation; includes wide range Has potential to become

sustainable

Specific targeting of the poorest

Values are transformed

Conventional community health

Goal: decreased maternal/infantmortality, morbidity etc.

Focus: programmes, activities Agenda set by organisation Fixed interventions; often limited

to MCH + water & sanitation Generally not sustainable -

changes in community often donot last if programme stops

Poorest of the poor often remainexcluded

Values often remain unchanged

Fig5 Chowdhury M, 1997

Fig610


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Unfortunately, there is much jargon associated with development. Terms like participation bringconfusion by being freely used to mean many different levels of community involvement. Others, likepraxis, mean nothing to people unfamiliar with a certain area of development language. A glossary ofterms is found at the back of the pack.

Finally, a few words of caution:

1. There is no such thing as the perfect project; the case studies highlight a few key areas demonstratingsuccessful practice but each of the projects has been subject to struggles common to projectimplementors everywhere.

2. These case studies are not in any way meant to represent a blue-print for project implementors

elsewhere. Each project should take the key principles and work through the relevance in their owncontext.

3. All the principles are covered but not in numerical order. So for instance, the ASHA study looks at

principles 3, 7, 8, 11, & 12.

11

Tearfunds learning materials and case studies may be adapted and reproduced for use provided thematerials are distributed free of charge. Full reference should be given to Tearfund and the relevant authorswithin the materials.


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Section Two

ABCD Overview of the programme

Clear vision, objectives and activities - principle 1Partnership with donors -principle 13

ASHA Overview of the programme

Community ownership -principle 3Skilled leadership -principle 7Appropriate activities - principle 8

Partnership with local and national government - principle 11Partnership with national/international non-government and communityorganisations - principle 12

JAMKHED Overview of the programme

Focus on the poor -principle 2Sharing of skills to support the development of communities - principle 4Resource mobilisation -principle 5Skilled, committed and motivated facilitators -principle 6Efficient monitoring mechanisms and evaluation framework - principle 9Secondary health referral -principle 10

CONCLUSION

S TU D Y P A C K FO R CO MM U NI T Y DE V EL O P ME NT WO R K ER S

Section Two



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ABCD Overview of the programme

Learning Objectives

The specific learning objectives for this study are to enable the reader to understand anddescribe the following key principles of community health development:1. Clear vision, objectives and activities -principle 1

2. Partnership with donors -principle 13

The ABCD(Agriculture,Business andCommunityDevelopment)programme is

based in three rural

communities (22,000 people) inCambodia. The focus of theprogramme is transformation ofpeople and their ability tomanage change. All the physicalchanges (credit schemes, waterpump programme, agricultureetc.) made by the communityare only tools that help themdevelop their ability to think,analyse and find solutions and tobe proactive towards change. Inpractice, the programme doesnot depend on a formula

method of working but onrelationships.The programme is implementedby western NGO, ChristianOutreach, who began running aprimary health care programmein the province in 1990. During avillage health survey, thevillagers asked for help insolving a wide range ofproblems beyond health. Theyrecognised the cause and effectof poor water supplies and

inadequate food on their generalwell-being and especially that oftheir children. Followingrecommendations from a periodof research and a pilotprogramme, a planned 7 yearprogramme began in 1994.

The entry point for beginning aprogramme in a village comeswith the villagers being carefullyencouraged to begin to discusstheir problems (animation).A priority need and the action to

be taken is agreed by the

vil lagers and Christian Outreach.Whatever they suggest isfollowed, depending only on thecost, and no value judgement ismade by the outsiders. The aimis to communicate that decisionsrest with the people and not

with the outsiders. Even if thissmall trust-building exercisefails, it still provides a discussionpoint for developing ability incritical analysis.At the f irst meeting, a VillageDevelopment Committee (VDC)of five to seven people is chosenby the villagers. The committeemeets with the programmeanimator to discuss all aspects oflife. The meetings are open toeveryone to help keep decision-making accountable to the wider

community. In addition, theanimators take walkabouts inthe village. At these times, theanimators form relationshipsand ask questions to developpeoples thinking. After muchdiscussion, the communitydecides together on actions thatwill improve the quality of l ifefor the poor. In the earlymonths, the animators onlyask questions. They do notgive information or offer

ideas until the villagers haveconfidence in their ownknowledge and experienceand the relationship is strongenough for them to be ableto disagree with theanimators.

The programme recognisesthree levels of informationimportant for communitydevelopment:1. Information in the

community (but not

necessarily shared): Duringthe first six months, theanimators questions shouldbe drawing out theinformation that exists in thecommunity but is notnecessarily discussed during

everyday life. Sharing thisinformation can bringbenefit to others in thecommunity.

2. Information within reach:

There is information that isnot in the community but iswithin its reach. An exampleof this might be the price ofa hand pump for sale in thelocal market. The animatorencourages the communityto find out this kind of

information for themselves.

3. Information beyond reach:discussion leads the group toseek information from theanimator which is sharedonce the relationship isstrong enough fordependency to be avoided.1

Fig7 Village in Prey VengJaeger M C, 1997, Tearfund

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Clear vision, objectives and activities - principle 1QThink of your own programme or one you know. What is its vision or goal?

The ABCD programme startedwith a clear vis ion or goal to

increase peoples ability toinitiate change and make choicesin an environment of lovingrelationships. The goal can beconsidered a guiding light to theprogramme for its philosophy,principles and methodology. Itshows the way towards thewider objectives:1. Alleviation of extreme rural

poverty in Prey Veng district2. Alleviation of feelings of war

trauma, isolation, fear andbeing violated

3. Sustainable replication of theprogramme.

The programme works towardsthe wider objectives by fulfillingits immediate objectives:1. Animated people who will

make benevolent changes intheir physical environmentand health after externalinputs have come to an end.

2. A healing environmentwhich breaks down barriers

of fear, isolation and thesense of having beenviolated.

3. Improvements in thephysical environment andhealth of three communesmade through participatoryprocess.

4. Replication of theprogramme by a Cambodian

organisation.5. Enterprises that createincome for the participantswith particular reference toassisting vulnerable groups.

The wider objectives are notexpected to be fulfilled withinthe life of the programme,whereas the immediateobjectives should be in place bythe end of the programme.Having identified the desiredobjectives, the planners define

what activities need to becompleted (outputs) in orderto achieve these objectives.

Examples of activities to becompleted include: 25 village development

committees established 25 development funds in

operation and managed bythe villagers

Regular antenatal careavailable in all three

communes

There is a clear link between thegoal, its objectives and itsactivities. The goal is theplumbline against which actionsin the programme are measured.Indicators of achievement givethe staff the means to measurewhether or not they are moving

towards the goal. For example,ABCD has decided on indicators

such as: Each of the 25 villagedevelopment committees tohave 5 meetings within thelast two years

20 development fundsmanaged through threefinancial cycles withemphasis on vulnerablegroups

More than six clinics held ineach commune every threemonths without externalinitiation.

ABCD is strengthened by havinga clearly stated vision withidentification of how this istranslated into objectives andoutputs. The programme retainsflexibility so that objectives canbe adapted as the situationchanges.

Discussion questions

1. Goals and objectives should coincide with the peoples goals and objectives.What might be some of the difficulties in gaining this kind of agreement?

2. What do you think are some of the reasons why objectives decided at thestart of a programme may need to change?

3. Does your project have clear vision, objectives and activities? Are theyclearly linked and regularly reviewed?

If YES, how have they changed as the programme has developed? Howmuch is the community involved in deciding on the objectives andactivities?

If NO, what plan could you make to decide on setting your programmesgoal, objectives and activities more clearly?

Fig8 Village development committeeJaeger M C, 1998, Tearfund

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Partnership with donor agencies- principle 13

QWhat does partnership mean to you?

ABCD is funded by both Westerngovernment aid and NGOs. The

funding is constructed in such away that it is not tied to theagenda of an outside agency. Itis flexible allowing the agenda tobe set by the people. Space isleft for the people to workwithin their own decisions andat their own pace withoutthreatening the responsibility ofChristian Outreach to theirdonors.The willingness of the agenciesto enter into a 5 year fundingcommitment is due at least inpart to the clear objectives,activities and measurableindicators set out at the start of

the programme. Also regularreports with clear explanations

for changes in plan, have keptthe donors informed of projectprogress.

The hands-off approach of ABCDmay seem to be risking a lot ofmoney as the villagers coulddecide on interventions whichare inappropriate. However, theABCD experience has shownthat, as long as the process doesnot become trapped in powerstructures (for example, not alldecisions should be made by thecommune leader), the decisionswill be relevant. The decisionsmade are transparent and

represent the majority of thevillage. In practice, the

programme has found that thisapproach has resulted in lessmoney being used and wastedthan with comparativepaternalistic interventions wherediscussion is not encouraged.

The donors have recognised thatgood development practicemeans that programmes muststart small and take time to buildrelationships. Willingness tofund the programme has grownfrom a relationship of trustbetween Christian Outreach andthe donors.

Discussion questions1. What difficulties have you experienced in working with donor agencies?

2. Make a plan to resolve these difficulties?

1From ABCD 96/97 Annual Report Appendix 2 and Batchelor S, 1997, Transforming the mind by wearing hats!

Agriculture, Business and Community Development (ABCD) Case Study, Tearfund.

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ASHA Overview of the programme

Learning Objectives

The specific learning objectives for this study are to enable the reader to understand anddescribe the following key principles of community health development:

1. Community ownership -principle 3

2. Skilled leadership -principle 7

3. Appropriate activities -principle 8

4. Partnership with local and national government -principle 11

5. Partnership with national/international non-government and community organisations -principle 12

ASHA (Action forSecuring Healthfor All) is acommunity anddevelopmentsociety working

in the slums of Delhi.Delhi has a total population of13 million and there are 1500slums with a population of 3.5million people living inmakeshift huts. Slums arecharacterised by enormoussocial problems. People come

from states all over India andoften only stay a short time inany one place. Slum dwellersoften feel very insecure. Theyare occupying land illegally anddemolition by the authoritiescan occur at any time.Therefore, they are oftenreluctant to invest money inimproving their homes andenvironment. Most slums haveno drinking water, sanitation orelectricity. In addition todiseases associated withinadequate water and sanitation,slum dwellers are also at riskfrom illnesses linked to pollutionand substance abuse. Also thereare very few people of influencewilling to speak on their behalf.

ASHA was born out of a vision tolove and serve the poor in thename and spirit of Christ. Thework began in 1988 in one slumof 4000 people, and by 1998 ithad grown to cover a population

of about 165,000 people in 21slums in various parts of the city.

The overall objective of ASHA isto improve the quality of life ofdisadvantaged urban dwellers.

ASHA builds trust andacceptance by offeringsubsidised curative clinics as itsfirst initiative with a community.As trust is developed, staff areable to mobilise and trainwomen health volunteers andtraditional birth attendants.Further mobilisation occursthrough womens action groups

(Mahila Mandals), which discusshealth and social issues. Thesegroups increasingly becomeinvolved in improving the slumsby their own direct action orlobbying civil services.

Significant progress has beenmade in improving the quality of

life. About 80% of childrenunder five in project areas arenow healthy and maternal healthhas also greatly improved. Inareas where the project hasworked longest, there issignificantly less diarrhoeal andacute respiratory disease1. All theslums in which ASHA now workshave some form of communitylatrine and water supply. Also,drainage and refuse disposalhave all been significantlyimproved. ASHA recognises that

empowerment is a key issue andtherefore seeks to ensure thatthis is the underlying basis of allits activities.

The aspects which have madethis a successful communityhealth development programmeinclude:

Fig 9 Ekta Vihar slum colonyWebb M, 1990, Tearfund 16


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Its holistic multi-sectoralapproach (see Appropriateactivities,principle 8)

Working at the invitation ofslum communities

Working with the

government, both to obtainservices and resources andto lobby for change

Developing goodrelationships with slum-lords(politically controlledindividuals who control theslum dwellers by extractingpayments)

Strong emphasis onempowerment and training

local people with aparticular emphasis onwomen

Insistence on communitycontribution andparticipation - avoiding

hand-outs Developing cost-effective andreproducible programmes

As far as possible facilitatingand empowering rather thanproviding.

Finally, the programme isunderpinned by Christianvalues: health is viewed as aholistic concept, with spiritual

needs as an important integralpart. An awareness of Godslove and concern for the poor isthe motivation behind ASHAswork. Service, honesty, integrityand respect for all are at the

heart of all programmes,regardless of caste, religiousstatus, family or economicsituation. In Dr Martins words:Our motivation to work amongthe poor in slum colonies comesfrom our devotion to Christ. Weare consumed with our desire tobring about real change inpeoples lives.....

1Infant death rate is 40 per 1000 (over 100 in other Delhi slums) Child mortality has fallen from 56 per100 in 1988 to 8 per 100 in 1997

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Community ownership - principle 3

QWhy is it important that health programmes are owned by the people?

One of ASHAs key strategies isempowerment and developmentof human potential. In theoutworking of this strategy, theslum-dwellers increasingly gainownership of the programme.

Community support is gained byASHA in two main ways: f irstlyby calling people from thecommunity to offer themselvesto become trained as healthvolunteers. This aspect of theprogramme follows a fairlyconventional model of

community health. However,rather than being paid by ASHA,the health workers charge feesfor service. This encouragesaccountability and involvementby the community and has beenseen to work even in the poorestcommunities.

Secondly, communityinvolvement occurs through theformation of the womens actiongroups, the Mahila Mandals. InIndia, the basic laws are just butoften poor people do not havethe confidence or solidarity toaccess these rights. The Mahila

Mandals give women theopportunity to voice theirproblems and work withneighbours to find solutions.They gain self confidence tospeak out for themselves andhave been considerably moreeffective in influencingsustainable health outcomesthan the established slum healthcommittees. 475 families in oneslum formed a co-operativehousing authority and were ableto transform their slum into acommunity with proper roads,

drainage, clean water, electricity,health centre, school, park and aclean environment. Anotherinnovative feature of thisinitiative was to encouragewomen to hold the legal title tothe new property in defenceagainst abandonment by theirhusbands. The ongoingmaintenance and managementof the community is funded bythe inhabitants via their housingco-operative. The peoplethemselves have become agentsof change.

ASHA has found that activeparticipation and ownership bythe community requires muchpatience and persistence. It hasidentified a number of ways thatcommunity participation can bemeasured. For example: byseeing attitude changes, thequality of input in meetings,how often meetings areattended, and levels ofindependence such as whetherpeople can access governmentservices alone.

In some slum areas, the workhas been totally handed overand the communities areinitiating their own changes. Forexample, many Mahila Mandalshave gone to other areas toteach. There have also been anumber of cases whereneighbouring slums have takenaction because they have seenthe beneficial effects in the slumswhere the ASHA programmeoperates. These are all examplesof how the programme seeks togive control or ownership of theactivities to the community.


1. What does community mean in the area where you work?2. What might be some of the difficulties in implementing this kind of community

health development programme in a slum?

3. What difficulties do you experience in gaining active participation and

community ownership in the programmes you implement? How might these beovercome?

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Skilled leadership - principle 7QIn your experience, what are the differences between a good and a bad leader?

ASHA was founded by Dr KiranMartin. Previously, she had

worked for a short t ime in ahealth centre for slum dwellers.Here she saw the potential of acommunity-based approach andher Christian faith played amajor part in her decisionmaking. She approached thecommunity and began to listento them. She then sought theassistance of the authorities toprovide a site for a health clinic.The director of the Delhi SlumWing was initially sceptical of

her approach but her persistencewon through. His helpfulnessnow is due to the relationshipbuilt by Dr Martin.

Dr Martins intuitiveunderstanding of how to involveeveryone through relationshipshas made the project succeed.Time and perseverance have ledto strong working relationshipswith both the government andthe slum landlords. This doesnot prevent Dr Martin from

challenging wrong decisions oractions if necessary.

Dr Martin demonstrates cross-cultural understanding andpractises principles ofimpartiality. She is able toidentify with and relate to thepoorest of the poor and in thenext moment give attention to

an important visiting official.60% of her time is spent with thecommunity. Her leadership stylewith ASHAs staff is one offriendly relationships. She is

will ing to spend time with boththe management of theprogramme and the cleaner ofthe clinic. She has seen anddeveloped the potential inuntrained staff, regardingmotivation and the right attitudeas more important thanappropriate professionalqualifications. For example, two

key staff members previouslyworked as a beautician andteacher respectively. Highquality support is especiallyimportant when staff lack formal

education or professional skills.Slum work is difficult and teammembers have often beenverbal ly and physically abused.Over the years, she has beenable to pass on her vision to thestaff. Her enthusiasm anddedication have been key in thisambitious and innovativeprogramme.


1. Dr Martin did not start the programme with a proven track record ofimplementing successful community health development programmes. What doyou think are the aspects of her leadership which have made the programmesuccessful?

2. What qualities of leadership are necessary in your programme?

Fig10 Dr Kiran Martin with women from Ekta ViharJaeger M C, 1997, Tearfund

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Appropriate activities - principle 8

QList the main activities in your programme. Describe how they enable your goal and activitiesto be achieved.

The activities of ASHA are consistent with its goal and objectives and are therefore appropriate. They are

centred around community empowerment leading to:improvement in health status; environmentalimprovement; and the development of community and individual potential .

Community based Primary Health Care

Community Health Volunteers(CHV) are the women who formthe backbone for most of thePHC work. Each CHV isresponsible for providingpromotive, preventive and somecurative health for about 200-300families in the area in which she

lives. This includes makingregular home visits, treatingsimple illnesses, referring toother services, promoting familyplanning, and health education.

The government built the 15slum clinics and continues to beresponsible for theirmaintenance whilst ASHA staffsand runs them. Weekly generaloutpatient clinics are held by adoctor. Antenatal andunderfives clinics are run by

CHVs. Child health educationand awareness-raising is alsoundertaken by the MahilaMandals. ASHA works with theMinistry of Health in organisingimmunisation campaigns.

Environmental and Sanitary improvements

ASHA sees this as critical becauseof the importance of theenvironment to health, socialand economic status. Despite

the municipal authoritieslimited resources, all the slumsin which ASHA works now havesome form of communitylatrine. ASHA has also supported

communities in negotiating fordrainage channels, brickpavements and a municipalrefuse disposal service. ASHA

facilitates communities, usuallythrough Mahila Mandals inpressing authorities for ongoingmaintenance, repairs andsupervising the quality of

cleanliness. The Mahila Mandalshave learnt to be strongprotesters when services breakdown and to encourage

communities to acceptresponsibility for achievingcleanliness in their own areas.

Empowerment and development of potential

ASHA believes that women, withtheir role in families andcommunities, are key in fightingpoverty. Therefore ASHA seeksto empower women in the

Mahila Mandalswithparticipatory training anddevelopment. There arecurrently 36 active MahilaMandals with a totalmembership of 930. Theiractivities include:- weeklymeetings to discuss relevantcommunity information and

agree appropriate responses; -systematic monitoring of thecommunitys health;- protestingtogether to slum leaders aboutsocial issues and injustices such

as the misuse of resources andpower;- lobbying municipal andgovernment authorities toachieve services; - four MahilaMandals run sewing centreswhere women pay to learnsimple sewing skills; two runday time child care centres toenable women without family

support to work;- working withanother NGO to run small creditand savings schemes for incomegenerating purposes.

A longterm initiative relating toempowerment is weeklychildrens clubs. Thisacknowledges the importance ofchildren growing up aware andinformed. There are a total of 36clubs with a membership of 818.

Fig11 Community health volunteer with amother and child

Webb M, 1990, Tearfund

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Training

Training is one of ASHAs keystrategies and is at the heart ofmost of its interventions. Eachclinic doctor runs regular

training sessions for the ASHAstaff and CHVs. Periodically,more formal programmes areheld, for example to train new

CHVs or educational focuses forMahila Mandals. Sometimestraining has been ongoing: forexample, how to organise

delegations to the government,how to write letters, how torecord statistics and keepaccounts etc. ASHA teaches by

example and training is on aparticipatory basis. Mosttraining is given by ASHA staffbut ASHA also makes use of

other relevant training coursesrun by the government andother NGOs.


1. Which of ASHAs activities would you consider to go beyond normalcommunity health activities, and why?

2. Why do other programmes not normally carry out these activties?

3. What aspects of these activities do you think have been important to the

success of the programme, and why?

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Partnership with local and national government - principle 11

QList all the ways your community health programme works with the local &national government

ASHA works on the principles ofacceptance and of authority notbeing intrinsically evil. This hasallowed the project to work withthe government to findsolutions, rather than beingconfrontational over itsweaknesses. In theory thegovernment in India iscommitted to affordable healthcare for all. There are manylaws for the protection of theweak but often these laws areabused by the people in

authority. The law is not wrong;it is the use of the law that iscorrupted.

ASHA has taken the approach ofworking towards co-operationwith the authorities. The localgovernment has learnt to trustand respect ASHA and hence iswilling to entrust them with theirlimited resources, knowing theywill be well used. Thegovernment authorities havegiven many false promises in thepast, but in its advocacy role, theproject has been able tonegotiate 23 buildings all paidfor by the government.

The relationship developed withMr Singh, the commissioner forthe Slum Wing, is key. Hegranted ASHA the site for theclinic. He also played a key rolein organising the finance fromthe bank for upgrading the slumas well as organising the

authorities to agree to the action.ASHA also works with the Slum

Wing to organise housing loansat a low interest rate with theOriental Bank of Commerce.

Importantly, Dr Martin has beenable to involve not just therelevant officials but also theunofficial officials, the slumlandlords. The fact that ASHA isnot trying to make money orachieve status and does not haveunderlying political motivations,means that the slum leaders havebecome more trusting and co-

operative.

Difficulties with the relationshiphave arisen when politicianshave given free distributions towin the votes of the people.This handout mentality isundermining. Also leaders havesometimes taken the credit forprogramme achievements suchas the new water scheme.

The Governments new housingpolicy has adopted the modeldeveloped by the MahilaMandals who transformed their

slum into an establishedcommunity.


1. What difficulties do you experience in working with governmentorganisations?

2. Make a plan to show how you could begin to improve this situationbearing in mind ASHAs experiences.

Fig12 Co-operation with the authoritiesS Batchelor, 1996, Transforming the slum by relationships, ASHA, Tearfund

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Partnership with national/international non-governmental

and community organisations - principle 12

QWhat are the positive and negative aspects of working in partnership with other NGOsand community organisations?

Where possible, ASHA workstogether with other organisationsin the area. It works in co-operation with other NGOs toprovide programmes such asvocat ional training, housing andmicro-enterprise. For example,in the micro-enterpriseprogramme, ASHA identifies thetarget group while the otherorganisation provides theteaching. Income generation

through the banks did not workbut has been successfullyimplemented through otherNGOs.

Only one other NGO is involvedin health in one of the locationsin which ASHA works, so there islittle risk of duplication ofservices. However, problemshave arisen over different salarypolicies. ASHA health volunteers

are not paid and staff receive arelatively small salary, whilesome other NGOs have adifferent ethos, offering relativelyhigh salaries. High salaries cancreate dependency and loss ofownership amongst slum-dwellers as they are not able topay for these workers. Alsothese differences can cause ASHAstaff to leave to find highersalaries elsewhere.

Discussion questions1. What are your experiences of partnership? Are they similar to ASHAs?2. In what ways can you improve and develop partnerships in your

programme?3. If you have not already done so, visit NGOs and community

organisations, which are based near to you. Find out if there are waysyou can work together and support each other. This does not have to be a

health related organisation. You may find you have a lot in commonwith organisations involved in agriculture and income generation forinstance.

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JAMKHED overview of the programme

24

Learning ObjectivesThe specific learning objectives for this study are to enable the reader to understand anddescribe the following key principles of community health development:

1. Focus on the poor -principle 22. Sharing of skills to support the development of communities -principle 43. Resource mobilisation -principle 54. Skilled, committed and motivated facilitators -principle 65. Efficient monitoring mechanisms and evaluation framework -principle 96. Secondary health referral -principle 10

JamkhedComprehensiveRural HealthProject is situatedapproximately250 miles east of

Bombay, India. It is the story ofpeople - of men and womenoutside the mainstream ofsociety, who have gained theself-esteem and self-confidencenecessary to determine theirown lives. It is also the story of

the development of a sustainablecommunity-based primary healthcare programme in one of thepoorest parts of India.... Poorilliterate men and women haveshown that Health for All canindeed become a reality, if onlythe professionals would allow itto be so. (Arole R.& M, 1994)

In 1970, Drs Raj and MabelleArole were invited by the leadersof Jamkhed, to provide healthcare to their community.

Starting with simple curativecare, the programme has spreadto 175 villages touching the livesof about a quarter of a millionpeople. Not only has it broughtbetter health to the people, it hasalso been a catalyst in the overalldevelopment of their lives.The programme works in anarea previously closed to all

Christian groups and is the onlyNGO working in health anddevelopment in the area.

The programme developscommunity groups such asfarmers clubs, womens groups(Mahila Mandals) and youthgroups, as well as trainingcommunity health volunteers.Increasingly, individualcommunities take responsibilityto collect and analyse

information and make actionplans. The groups become self-reliant in promoting non-medical interventions whichdetermine health such asorganising water supply,improving agriculture, anddealing with unjust socialstructures and practices.Specific health programmes areorganised for women andchildren as well as for controland rehabilitation for leprosyand tuberculosis. Great

emphasis is placed on sharinginformation constantly andupgrading peoples knowledgebase and skills. Villagers andgrass-root workers are treatedwith respect and their goodideas are implemented in theprogramme.

During a time when the Aroleswere not actively involved in theprogramme, groups of Jamkhedvillagers went to stay in villagesover 200km away. Theyorganised Mahila Mandals andidentified and trained VHWs.One of the Jamkhed villagersreported the tribal people arevery poor. They are friendly andinvited us to stay with them andshare what they had. It wasdifficult for me because there

was no water and there was filthand flies all around. Almostevery family had scabies andskin infections. We had nochoice; we had to stay in theovercrowded huts. Then Iremembered that once we toohad filth in our village and therewas scabies. All of usdetermined to first get rid of thescabies just as we had done inJamkhed. Water had to befetched from a long distance.This did not deter us. We

worked with the people and inthree months got rid of thescabies. We encouraged thewomen to be involved in healthactivities; in spite of the physicalhardships, it was a rewardingexperience.


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Fig13 Graph showing decrease in malnutrition rate

Fig14 Graph showing increase in immunisation rate


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Focus on the poor - principle 2

QWho are the poorest people in the communities you work in? Why are they poor?

For centuries Indian society hasbeen divided into numerousdifferent castes. The Brahminsor priests are considered to bethe highest group. Othersinclude business men andlandowners. Outside the castes,and not even included as acategory, are the untouchablesand Dalits. They are forced tolive outside the village and onlygiven the dirtiest, mostunpleasant work. Women,children and people withleprosy are also marginalised.

Officially, the government haspassed a law against treatingsome groups as untouchable butin practice the discriminationcontinues. This results inextreme poverty, oppression andapathy.

In their eagerness to serve thepoor, the Aroles learnt that theyshould not antagonise theleadership. In the initial stages,they took the existing leadersinto their confidence andgradually worked with the other

vil lagers until true leadershipemerged among them. Sincewomen had no place in vil lagesociety outside the home, workinitially began with the men.Farmers involved in healthsurveys saw the suffering of thepoorest and began to planactions to meet the mostpressing needs. It becameevident that health was not thepriority of the poor at all. Themajority were concerned withtheir very survival: work andfood. To break down the

barriers of marginalisation andcaste, several interventions wereinitiated. Children of all castescook and eat together and Dalitsare encouraged to serve thefood. Womens self esteem wasbuilt up through the MahilaMandal groups.

As the poorest people areempowered, efforts atreconciliation and co-operationamong different groups areemphasised. Since health isdependent on the villagecommunity as a whole, itinvolves interconnected aspectsof life. Often the individual canaffect these only when there isco-operation among themembers of the community forthe benefit of all. There is muchevidence of empowerment inJamkhed; in many villages thereis no longer any fear of socialexclusion. Overcoming thecaste system has not been an end

in itself but a means to an end.The purpose is fortransformation to self-reliancefor the village as a whole.

Fig15 A) Diagrammatic map showing how dalits are not included in Ghodegaon Village

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27

Discussion questions1. How do you think a CHD programme should decide where to target its

activities?2. How do you target the activities of your programme?3. Now you have read about Jamkheds experience, are there other ways of

targeting you might use?4. Make a plan to show new ways that your programme could target its

activities.

Fig15 B) Diagrammatic map showing how dalits are now included in Ghodegaon VillageArole M & R, 1994, Jamkhed A comprehensive rural health project, Macmillan/TALC page 12 & 13.


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Sharing of skills to support the development of communities - principle 4

QHow could different people in a community get actively involved in health care?

Jamkhed has discovered thatrural communities are capableof planning and maintainingtheir own health, provided theyare taken seriously and nottreated as ignorant people.The staff entrust health servicesto the people and the attitude ofsuperiority is replaced by afeeling of equality and workingtowards a common goal. Staffhave learnt to have faith thatpoor illiterate woman can gainthe skills they themselves have.A staff member has said all that

I know the villagers can know; itis my responsibility to decidehow to transfer my knowledgeand values to them.

Everyone in the community hasthe opportunity for skilldevelopment, so that changedoes not rest with a few VillageHealth Workers or TBAs. Thisalso avoids the risk of thembecoming self-important experts.They receive their training in thecommunity so that everyone canknow what they know. Forexample, even the old men inthe community can accuratelydescribe how a baby should bedelivered. Skill-sharing iscombined with development ofvalues.

Village people have experienceof coping with difficult

conditions and have many usefulhome remedies. These arepromoted together withappropriate moderntechnologies such as simpleinfant delivery packs and oralrehydration. The mystery ofmedicine is removed. In thecase of harmful traditionalpractices, scientific informationis provided and health workersare allowed to discover forthemselves the effectiveness ofscientific interventions.Information-sharing builds on

positive traditional practices,never directly discrediting any

practice.

Skill-sharing has evolved as partof an ongoing process. Themessage does not stay the samebut new information is sharedaccording to current communityconcerns and hence knowledgeis built up over the years. Forexample, more recently in somevillages, the community hasarranged for most adults to havetheir blood group identified, sothat if a woman has difficulty inlabour, several people with the

same blood group go with her tohospital.

Discussion question1. What do you think are the Strengths, Weaknesses, Opportunities andThreats (SWOT) of the way Jamkhed shares skills?

2. Describe or make a drawing to show how skills are shared in your

programme and with whom

Fig16Village health worker with village womenArole M & R 1994 Jamkhed A comprehensive rural health project,

Macmillan/TALC page 197

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Resource mobilisation - principle 5QWhere do the resources come from to run your programme?

From the beginning, the Arolesused a programme planning,

budgeting and review systemwith the objective of developinga sustainable health programme.

The cost of care is discussedwith the people using the datafrom morbidity surveys. It wasagreed that recurrent operatingcosts would be kept low so thatthe village people could affordto pay for the services. Costs areconstantly reviewed in relationto the objectives, such asreducing infant and maternal

mortality, rather than in relationto maintenance of institutionssuch as a hospital. If aprogramme is not cost-effective,it is discussed with the peopleand either modified ordiscontinued. Therefore, whenit was found that health centresin two of the areas were notcontributing significantly to thehealth objectives, they werediscontinued. Instead, primarycare through village health

workers was strengthened and aneighbouring health centre wasupgraded to a small hospital.As far as possible, resources aregenerated locally while externalfunding is sought for capitalexpenditure and for seed moneyto initiate crucial programmes.Money from international

donors was used to establish thecurative services. Four years

later, the medical aspects of theprogramme were being met withfunds generated from thecommunity, the government anda few local donors. From 1975,little external funding has beenused except for specialprogrammes such as leprosy andtuberculosis control.

Initially new programmes suchas immunisation and familyplanning have to be promoted.Now local awareness has grown

to the extent that if these servicesare not available throughgovernment sources, thecommunity pays for them. Morerecently, many villages decidedon mass tetanus immunisationfor the adult population. Theycollected the money and heldthe campaigns. Likewise VillageHealth Workers charge for theirservices rather than receive asalary. Contribution by thevillagers is in spite of their

poverty. As social and culturalbarriers have been brokendown, unity and care havegrown so that villagers havefound ways for even the poorestto receive the health care theyneed. The mobilisation of localresources has resulted in a highlevel of programme

sustainability. (See alsoPrinciple 10, Secondary Referral,

page 32 )

As the project evolved into amore holistic multi-disciplinaryapproach, many non-medicalinterventions were introduced.For instance, provision of safedrinking water to the villagesrequired a large initialinvestment: 100 wells cost$70,000. However, the benefitsof a clean water supply reducedmorbidity and mortality by over50%. The expansion of the

programme has encouraged thevillagers to work towards self -reliance. They are able now tomobilise resources from withinthe community and fromgovernment agencies and bankloans.


1. Why is resource mobilisation important for achieving programmesustainability?

2. What outside expertise is available in your area?3. Do an assessment of your programme to see what types of resources you

would need to make it more sustainable.4. Draw a diagram to show the type of resources you need, and which can

be obtained within the community and which from outside.

Fig17 Villagers working together to conserve waterJaeger M C, 1997, Tearfund

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Skilled, committed and motivated facilitators - principle 6

QWhat qualites would a health worker need to become a good facilitator?

Initially, the Jamkhed staff hadno skills, experience orqualifications. In fact it can bedifficult in India to recruitChristian workers with thenecessary skills, especially athigher levels. All staff receivecontinuous on-the-job training,including in the values and goalsof the programme. Self-confidence is promoted at alllevels. Staff recognise that theprocess of enabling andempowering others and sharingknowledge and skills can only

occur if they themselves havedeveloped self-esteem. They allwork in partnership. But firstthe hierarchy had to be brokenin their own team. This meantthat the Aroles refused from dayone of the programme to betreated differently from the restof the team. All meals weretaken with everyone from thedoctors to the driver sittingtogether in a circle. Hierarchicalattitudes have been replaced bya team spirit and equality. Theteam has also realised thatknowledge not only gives power,but that sharing knowledge alsoincreases self-esteem and isimportant in the development ofteam spirit. While individualtalents are developed and

existing skills improved, it isnecessary for legal reasons tohave some staff with professionalqualifications. For example, aqualified Assistant Nurse Midwifemay be needed for some mobileteam work.

The villagers themselves say It isnot important to haveprofessional staff. Their attitudetowards us is more important.They should not be arrogant, butbe willing to identify whatpeople know already. They

need to be able to convincepeople that what they are doingis not for themselves, butbecause they believe in it; theirlives should be transparent andwithout suspicion in order towin the trust of the people; itcomes through love andforgiveness.

The following storydemonstrates how the potentialof an uneducated staff memberwas recognised and developed.Moses Guram joined the team asa construction worker helping tobuild the health centre. Hespent his time watching themotor mechanics, X-raytechnician and electricians andbecause of his aptitude and

interest, acquired many newskills. Eventually, he learnt howto make appropriate artificiallimbs for people who have hadan amputation, and he is now incharge of a workshop thatmanufactures equipment forphysically handicapped people.He says I was trusted andknowledge was freely availablein Jamkhed. Others shared theirknowledge and skills with me. Iwas nobody. Today I am calleddoctor and many doctors andprofessionals take my advice. I

share all the knowledge I havewith the young men who workwith me. Money cannot buy thejoy that I have in my work.

Discussion questions1. List the skills needed to be a community health development worker.

2. What do you think might be some of the difficulties that highly qualifiedprofessionals have with involvement in CHD? Do you have thesedifficulties in your programme? If yes, what are they?

3. Staff support is a difficult area for many programmes. What is your own

experience?4. Imagine you have been asked by your leader to a) identify the Strengths,

Weaknesses, Opportunities and Threats (SWOT) of adapting an approachlike Jamkheds to your programme, and b) draw a table to explain it.

Fig18Moses fitting a limbArole M & R, 1994, Jamkhed A comprehensiverural health project, Macmillan/TALC page 103

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Efficient monitoring mechanisms and evaluation framework - principle 9

QWho is monitoring & evaluating for, and why?

From the start, Jamkhed staffbelieved that if people are to beinvolved in the decision-making,planning and implementation ofprogrammes, they need to assesswhether their programmes areworking towards the objectivesthey have set.Gathering health informationfrom house to house has becomean annual feature. Members ofthe various groups in the village

design questionnaires so that

only necessary information iscollected. The staff team providetechnical input whereverneeded. The survey helpsvillagers to assess their healthstatus periodically. This providesthe basis for discussion atmeetings and inspires them tolook for solutions, for exampleto problems of widespreadmalnutrition or high incidenceof malaria. It also helps them toidentify the impact of healtheducation so that the villagehealth worker can target heractivities. It is a learning processfor everyone involved. Theinformation is not a set of figuresto be sent to a distant official buta tool for improving the servicesin the village. The programmestaff systematically collect andcollate the information from thedifferent villages for preparationof programme reports, butcontrol of information in

individual villages remains with

the villagers.

For many years each village haskept its own statistics board. Asdifferent issues becomeimportant, different indicatorshave evolved. They are specificto each village because each hasits own problems. The villagerssay It is not so much thestatistics were interested in buthow things are changing; forexample getting rid of bad habitsand what we are eating. Wemeet every day to discuss thedays events. It is no big thing.Everyone knows about health; iftheres a birth or death, wediscuss it immediately. If a childdies, the whole village wants toknow why. The frequency ofrecording depends on the actualdata, so, for example, new TBcases are recorded weekly whilstfamily planning data is updatedevery three months.

Section three page 45 describes an evaluation carried out by villagers of the non-medical aspectsof the programme.


1. List some of the advantages and disadvantages of keeping statistics.2. How is your programme monitored and evaluated? How does this differ from

Jamkhed?3. Are there aspects of the Jamkhed approach to monitoring and evaluation which

you could usefully adapt for your own programme? Write down the steps you

would need to take to do this.

Fig19 Villager in Ghodegaon explaining their statisticson the board

Jaeger M C, 1997, Tearfund

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Secondary health care services for referral or networking purposes

- principle 10

QWhy are secondary health services important?

A simple forty-bed hospital withdiagnostic and surgical facilitiessupports the primary healthprogramme. It is run by theprogramme staff on the Jamkhedethos.Special efforts have been madeto keep the cost of secondarycare within the reach of thevillage people. By usingoverlapping job responsibilities,the cost of hospital personnel iskept at a minimum. When

specialist services are needed,they are carried out throughmass campaigns, for example, ineye camps. The hotel costs ofcare for patients are alsominimal; relatives cook, cleanand help in the nursing carewhich is in keeping with thelocal culture. The building is alow cost design and costs arefurther cut by only usingappropriate technology.However, at no point is scientificsterile technique sacrificed. Thecost of medicine is reduced byusing medicines from the WHOessential drug list bought in bulkfrom reputable companiesselling generic drugs.

The hospital uses an effectivecost recovery scheme. Theprogramme found that ifeveryone, including the poorest,knows what the services cost,they will be more ready to pay if

they can afford it. Totally freecare is often not respected andvalued. Discussions with thefarmers clubs and MahilaMandals have enabled thehospital to set fees that arewithin the ability of the poorersectors to pay. Approximately50% of the community can pay alittle more than the cost oftreatment, to offset costs forthose whose treatment issubsidised. About 10% of

patients cannot pay. The groupsidentify such people and workout ways of meeting the costs.The community may meet thecost through contributions or anarrangement may be made tocontribute labour in some form.

The programme staff aim for a

balance between curative,promotive and preventive healthservices. They have seen thatpoor communities have a largebacklog of disease. People needcurative services for theirimmediate medical problems.These services can act as anopening for preventiveprogrammes.Primary health care needs thesupport of secondary services.The village health worker must

have the confidence that she canapproach a secondary carecentre for help when needed.Antenatal care without a back-upservice for Ceasarean sectionwill soon lose all credibili ty.Therefore, it is acknowledgedthat secondary facilities willalways be needed.

Discussion question

1. What might be some of the problems associated with hospitals in relationto CHD programmes?

Fig20The Two Mules-Everyone benefits when hospitals and primary healthprogrammes work togetherTALC

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CONCLUSIONThe case studies have described how three programmes demonstrate the principles necessary for effectivecommunity health development. They have much in common. All three have a clear vision to improvethe quality of life especially for the poorest. Two of the three (ASHA and Jamkhed) were started bymedical doctors with small curative programmes as the entry point. However, all three have realised thatto fulfil their vision, health must be seen in its broadest sense and programmes need to be integrated andinclude non-medical interventions. But more than this, they recognise the importance of facilitating truecommunity ownership of the programme. This means that individual villagers (or slum-dwellers) learn towork together in community organisations to take responsibility for changes in their l ives. Skills andknowledge are freely shared between staff and community and within the community. Staff andcommunity work together to break down social barriers and build relationships based on mutual respectand trust.

The studies illustrate the importance of skilled leadership in living the values of community healthdevelopment, understanding the communities, inspiring and training the staff and generatingcommitment from the authorities. This means relationship-building at all levels. Leaders and staff areseen to work as facilitators with the community. Partnership is also built with both government and non-government organisations. Resources are generated locally where possible and appropriate low-cost

technologies used. The importance of affordable secondary care, that is supportive of community health,is acknowledged.

Finally, there is a common thread running through all three studies: that in each case the work is basedon Christian values. This means that every man, woman and child is treated with respect and givendignity and everyone grows towards their full potential.

Concluding questions/activities

1. Review each of the 13 principles. What are the strengths, weaknesses,opportunities and threats of including these principles into your programme?

2. Make an action plan for implementation of changes you would like to see in yourprogramme in relation to the 13 principles. Please see Action plans in sectionthree, page 46.

3. You may find it helpful to visit or get in touch with other organisations or groups

in your locality. They may be wanting to know and learn similar things to youabout how best to work in the community. Also, although this case study and theguidelines relate to community health many of the principles apply whatever thespecialism. It may be interesting to find out what a local agriculturalorganisations experience is of, for instance, focus on the poor, communityownership and skills sharing.

4. If you havent already done so, you could visit your local or national government

health department to find out in what ways you can work with them. You mayfind that there are resources available to you to support your work. This visit maydevelop into a good working relationship with governmental officials that willassist you in the future.

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Section ThreeS TU D Y P A C K FO R CO MM U NI T Y DE V EL O P ME NT WO R K ER S

Section Three

Comments on discussion questionsStudying in small groups

Evaluation of non-medical aspects of community health development

Action plans

Guidelines for good practice in community health development

Glossary

Abbreviations

Recommended reading and references


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COMMENTS ON DISCUSSION QUESTIONS

We, the author and editor, are aware that we cannot provide individual feedback to the questions wehave posed. Instead, we have written our comments and conclusions below. We would like to stress that

these are only our opinions and should not be taken as the final or only answers. Also, we have notanswered all the questions as some relate directly to the specific situation of the reader.

ABCD

Clear vision, objectives and activities - principle 1

1. Goals and objectives should coincide with the peoples goals and objectives. What might besome of the difficulties in gaining this kind of agreement?

2. What do you think are some of the reasons why objectives decided at the start of aprogramme may need to change?

3. Does your project have clear vision, objectives and activities? Are they clearly linked andregularly reviewed?

If YES, how have they changed as the programme has developed? How much is thecommunity involved in deciding on the objectives and activities?

IfNO, what plan could you make to decide on setting your programmes goal, objectives andactivities more clearly?

1.

At the start, neither villagers nor some staff may be able to set goals and objectives.

There should not be a blue-print for the work. Each village should decide on its own priorities.

The programmes can be determined by the peoples goals so long as they are value-based. Forexample, at the start the community may not be interested in the status of women so it is first

necessary to develop understanding of the value of women. It may be necessary to start a programme without the community being fully involved. Some

groups within the community are likely to be more involved than others.

It takes wisdom to know when to wait for the community to fully agree and when to try asmall demonstration programme; it will vary from one situation to another.

It cannot be assumed from the start that the community knows everything: if they kneweverything, they would not be where they are.

Concentration on objectives can change the focus from the community on to the project.

2.

The goal of bringing health to the poorest remains, but specific objectives and activities need tochange according to changes in priorities.

For example, after three years, ABCD undertook a major review of its objectives and adaptedthe whole framework to be more gender sensitive. This was in response to awareness-raisingof gender issues.

Political instability, difficulties in recruiting staff and security incidents have all caused delaysand changes in ABCDs original plans.

Other reasons for changing objectives and activities could be in response to changing healthpatterns, as the programme makes progress in addressing priorities identified in the initialassessment.

You may find it helpful to refer to the Planning, Monitoring and Reporting Manual(Brown S,1997)

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Partnership with donor agencies - principle 13

1. What difficulties have you experienced in working with donor agencies?2. Make a plan to resolve these difficulties?

1. It is very difficult, for example, when donors expect detailed forecasts of half yearly plans forthe next 3 years.

The format for reporting should be simple to reduce the time spent on it and should be user-friendly for smaller organisations. The Planning Monitoring Reporting manual

(Brown S, 1997) gives helpful suggestions on reporting.

A lot depends on donor attitudes; donors need to be willing to enter into partnership notdictate terms. Sometimes donors insist on specific activities which may not be appropriate.

There is need for flexibility with budgets because of unforeseen circumstances that can arise.Timescales for budgets vary a lot - one situation may take 6 weeks, another 3 years - the poorerthe village, the harder it is.

There are benefits in spreading the funding between several donors though this may meanconsiderable time having to be given to administration and report writing in order to followthe requirements of different funders.

2.

Some points to consider

Giving time to relationship-building is key in any partnership.

It is helpful to clarify that the visions and strategies of the different partners are consistent witheach other.

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ASHAOwnership by the community - principle 31. What does community mean in the area where you work?2. What might be some of the difficulties in implementing this kind of community health

development programme in a slum?3. What difficulties do you experience in gaining active participation and community

ownership in the programmes you implement? How might these be overcome?

1.

The question continually arises: What is community in a slum? Urban slum communities are oftenmade up of a mobile group of people who do not tend to stay long but move on in search of alivelihood. Such communities are also heterogeneous; people come from different states andcultures. These factors make unity and working together hard. In addition, some slumpopulations tend to be large (30-40,000 people). The size of the slum affects the ownership of theproject and more often ownership is limited to a small section. Much time needs to be given torelationship building. Local politics can make local NGOs, like ASHA, vulnerable as it can pose

limits on what they can do. On such occasions ASHA have had to stop a project, finding itimpossible to work in that slum. Yet in spite of the difficulties and because of their love, skill andpersistence, ASHA has seen large numbers of slum-dwellers able to form groups and helpthemselves towards significantly improved health an

Documents

Community Health(1)-Community Health Study Pack