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From: Partnership in health – Footsteps 12

Preventative healthcare in community settings

by Isabel Carter and Ted Lankester.

Developing partnership

Primary health care is often only thought of in medical terms. However, the key to successful community based health care is to work in partnership with the community.  This, an often revolutionary aim, is too often neglected.

As health workers, our chief task is to enable communities to set up and manage their own health programmes. When health care is provided through large curative institutions, funded by the government and other agencies and dominated by doctors, people come to expect things to be given to them and done for them. However, our aim should be to promote health care with the people, not to provide medical care for them.

Partnership will bring dignity to the poor. People soon realise that they no longer need others to do things for them, or give things to them. They come to see that they can do things and obtain things for themselves. This new self-reliance gives a sense of value and worth. The ASHA project in India has transformed the lives of many of the women training as CHWs. They have developed a sense of self-reliance, determination and power - realising that together they can make real changes in their communities. Partnership means that equipment is better looked after. When people feel it is their clinic, their forestry plantation, their water pump, they will take pride in looking after it.

Preparing ourselves

We will never work in genuine partnership unless our own minds and attitudes are carefully prepared. We will need to be...

The biggest block to participation is not the unwillingness of the community. It is the possessive attitude of the health worker wanting to gain credit and keep control.

Preparing the community

Partnership will not just happen if we arrange a few meetings and hope for the best. Like other community health skills, the ability to bring about participation has to be learnt and practised. At the beginning, many of the poorest, neediest and most exploited communities will not be ready to participate.

How can we ‘teach’ participation?

First steps in partnership

It is helpful for the community first to learn how to take an active part in one main activity. Later this can be extended to others.

A good subject to choose should be seen as a need by the community, should be within reach, and should bring an early, obvious benefit.

For example, one project was able to work with the community in sinking tubewells, so bringing clean drinking water and ridding the community of guinea worm. All were excited and wanted to work together on a further activity.

Other improvements may not be so immediately obvious. The community may fail to notice changes unless they are helped to look back and see how much things have improved since they started. We must teach the community to evaluate progress in terms of real changes.

Avoiding the pitfalls 

Common ones include...

Participation is a powerful process. Carried forward correctly it can help the poor, include the rich and benefit the community. Handled wrongly, it can leave a community wounded and unstable.

Supporting the community health worker

When first trained, the CHWs will rely heavily on the health team and the supervisor. The community may not believe in them, their families may mis-understand them; they may scarcely believe in themselves. They will need back-up and regular meetings with the other CHWs to encourage them, and to see that others are facing similar situations.

The village health committee is a vital part of the support for a CHW. The committee should be made up of committed, responsible villagers who have a concern for the poorer members of the community. Members should be encouraged and receive training for their role.

As they gain in maturity and knowledge, the CHWs will learn self-dependence and outside support will be less necessary. They will receive more of their encouragement from the community and their own sense of self-worth.

Should a CHW be paid?

This is one of the hardest questions to answer in community based health care. Arguments over CHW salaries are one of the commonest causes of failure in primary health work.

Wherever possible we should aim to set up CHW programmes in partnership with the community where CHWs are unpaid. This may be possible under the following circumstances:

It needs to be made clear that appointment as a CHW is not a path to fame and fortune either for the CHW or their family!

If payment does appear to be essential, there are various methods that can be used. 

Don’t start paying salaries that cannot be maintained. The world has too many CHWs who were well paid at the start and have now stopped working because the project has run out of money. It is better for CHWs to start receiving no wages or low wages that can continue, rather than high wages that have to be stopped.

In conclusion, community involvement seems to be the basis of almost every successful, long-term health programme.

Genuine partnership will make a project permanent. If people themselves learn to change wrong health patterns and adopt correct ones, then when the experts leave and the funding stops, their health will be permanently improved. 

This article was compiled by Isabel Carter, based largely on material from Dr Ted Lankester’s new book ‘Setting Up Community Health Programmes’ (which will be reviewed in the next issue). We would welcome letters which continue the discussion on these issues.

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