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25 JAN 2017
icddr,b scientists investigate whether increased community participation through self-help organisations can strengthen the function and implementation of health activities in resource-poor rural communities
According to the WHO, grassroots community participation in public health is a fundamental basis of successful health promotion. This study evaluates the success of participatory community health initiatives carried out through self-help organisations in improving community health in Chakaria, Bangladesh (a village that is affected by cyclones and climate change).
Self-help organisations can improve community health in resource-poor settings. Photo: icddr,b / Shehzad Noorani
Participatory action research (PAR) is a research paradigm that emphasises community participation and action. It draws on a wide range of influences, particularly the revolutionary work of Brazilian educator Paulo Friere. PAR rejects the coercive imposition of interventions on resource-deprived communities by external experts. Instead, it seeks to create a framework for a cooperative process where researchers and community members can contribute equally to the development of solutions.
Many rural communities address their collective needs through self-help organisations (SHOs) such as youth clubs and mosque organisations. These SHOs present an ideal target for PAR interventions targeting community involvement in public health. A team of icddr,b researchers lead by Dr Abbas Bhuiya, principal investigator and former deputy executive director of icddr,b, used PAR methods (including focus group discussions and people’s participatory planning) to strengthen the ability of SHOs to meet public health needs in Chakaria.
The study, published in BMC Health Services Research, finds that SHOs can effectively promote health after PAR mediated reforms - in the intervention area there was an increase in immunisation, skilled birth attendance, facility deliveries and sanitary latrines. Furthermore,through these efforts, local SHOs were able to improve their organisational management, e.g. the SHOs implemented monitoring systems for internal evaluation, yearly action plans and plans for leadership and organisational development. The SHOs also set up successful programmes for training village doctors that culminated in trained doctors promoting telemedicine services. The SHOs have also created micro-health insurance services that people have begun to enroll in such as a low cost Family Health Care card scheme. The SHOs also organised health camps for issues such as circumcision, and ear, nose and throat diseases. There was also a substantial increase in immunisations, skilled birth attendance, facility deliveries and sanitary latrines due to this intervention.
Between 1994 and 2015, the number of SHOs increased from 45 to 93. In 1994, 0% of SHOs had health matters as an agenda in regular meetings, developing and implementing action plans and monitoring progress and impact. By 2015, 42% of SHOs discussed health matters regularly.
Dr Bhuiya says, ‘The key is to listen to the community, showing respect to their concerns and jointly acting to tackle them. Wherever possible interventions should be in partnership with existing community organisations for it will not only increase the chances of success, but will also make the change lasting and will strengthen the local level organisation of the people.’
However, Dr Bhuiya acknowledges that the biggest challenges are building community trust, ensuring social inclusion and balancing demands for materials and responsiveness. The researchers initially faced a lot of anti-NGO sentiment in the village, and had to persevere to gain their trust. Dr Bhuiya reiterates, ‘Any initiative of this kind to unlock community capability has to have the realisation that there are no shortcuts and that fixed blue prints are unlikely to work. Our experiences highlight that to succeed over the long term, it is imperative to involve the community in development activities, supporting their capabilities and ownership of community health requires deeper engagement. Without their involvement, health planners and managers are unlikely to achieve their goals’’
Despite these challenges, the study demonstrates that working with local SHOs in the framework of PAR techniques can provide major gains to public health outcomes and empowers local communities to manage their own health without being dependent on external organisations.
Mr Shahidul Hoque, co-investigator of this study says, ‘Any investment on community created and owned organisations empowers and equips the community to tackle future challenges. This includes efforts to build and maintain trust, and balancing the burden for material resources with flexibility to respond to community needs.’
The project was funded by a consortium of Swiss, German and Dutch Red Cross Societies during the initial years. The present analysis and the paper were funded by DFID through Future Health System Project of Johns Hopkins University under the DFID Research Consortium on Effective Service Delivery.