Presented by:Narendra Singh

PG JR 1 Department of Community Medicine

What is a Community ?????

“A Community is a set of people living in a particular space or region and usually linked by common interest”

We all live in a community.

WHAT IS PARTICIPATION??????A/C to Oxford dictionary Participation means

“to have a share in ” or “ to take part in”.

WHY COMMUNITY PARTICIPATION IS IMPORTANT??

Participatory development and participation in development

Participatory development Participation in development

A top down participation in the sense that the management of the project defines where, when and how much the people can participate.

Bottom up participation in the sense that the local people have full control over the processes and the project provides for necessary flexibility.

It is introduced within the predetermined project framework.

Entails genuine efforts to engage in practices which openly and radically encourage people’s participation.

“As an individual I could do nothing. As a group we could find a way to solve each other’s problems”

• Success of any intervention in development and work depends on the confidence built and the power given to people to decide and take community initiatives.

CONSENSUS IS ITS KEY• The primary factor for promoting consensus and

instilling confidence is PARTICIPATION.

INTRODUCTION

• Development intervention approaches in INDIA over the past 60 years have been very much a ‘supply oriented one way traffic’.

LIMITATIONS OF THE APPROACHES

A top down approachTarget orientedNon involvement of the peopleVertically controlled sectoral approach without any horizontal

coordination The dominant development thinking oriented towards greater

inputs (supply) than what people demandedNear total absence of self confidence and even self respectLack of appreciation and promotion of indigenous technical

knowledge and resources.The ever growing recipient attitude.

COMMUNITY PARTICIPATION

• a process by which people are enabled to become actively and genuinely involved in defining the issues of concern to them, in making decisions about factors that affect their lives, in formulating and implementing policies, in planning, developing and delivering services and in taking action to achieve change’

WHO SAYS

Community participation is a process by which individuals

and families assume responsibility for their own health and welfare and for those of community and

develop capacity to contribute to their and the community development.

HISTORICAL BACKGROUND• Establishment of primary health units at the village

level to bring the service as close to the people as possible, cooperation of the people in the health programme, and adequate medical care for all individuals, irrespective of their ability to pay for it, were included in BHORE REPORT.

• COMMUNITY DEVELOPMENT PROGRAMME LAUNCHED IN 1952, the setting up of one Primary Health Centre (PHC) per Block was accepted by the Central Council of Health in 1953 .

THE SHRIVASTAVA COMMITTEE: Employment of paraprofessional or semi-professional workers from the community itself as a link between the Sub-Centers and the community to provide simple services was one proposal.

They opted for the Community Health Worker

scheme to meet the insufficiency of doctors.

Contd…

The Primary Health Care Movement towards Health for All by 2000AD Alma Ata, 1977

• Emphasis from

“Health care for the people”

“Health care by the people”

concept of primary health care Democratization of the health services

The International Conference on Primary Health Care calls for urgent action by all governments, all health and development workers, and the world community to protect and promote the health of all the

people of the world by the year 2000.

Alma Ata declarationDEFINED PRIMARY HEALTH CARE:“essential health care based on practical, scientifically sound, and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination” (WHO, Alma Ata Declaration VI, 1978, p.1).

STAGES OF PARTICIAPTIONLevel I.

• Community receives benefits from the service but contributes nothing

Level II

• Some personnel, financial or material contribution from the community ,but not involved in decision making.

Level

III

• Community participates in lower level decision making

Level

IV

• Participation goes beyond lower level decision making to monitoring and policy making

Level V

• program is entirely run by the community ,except for some external financial and technical assistance.

DEGREES OF COMMUNITY PARTICIPATION

Away

from

ow

nersh

ip a

nd sust

ainab

ility

Tow

ard

owne

rshi

p an

d su

stai

nabi

lityCollective action

Co-learning

Cooperation

Consultation

Compliance

Co-option

• Co-option• Token involvement of local people• Representatives are chosen, but have no real input or power

• Compliance• Tasks are assigned, with INCENTIVES• Outsiders decide agenda and direct the process

• Consultation• Local opinions are asked• Outsiders analyze and decide on a course of action.

• Cooperation• Local people work together with outsiders to determine priorities• Responsibility remains with outsiders for directing the process

• Co-learning• Local people and outsiders share their knowledge to create new

understanding• Local people and outsiders work together to form action plans with

outsiders facilitation

Community Action Cycle

Prepare to scale up

Prepare to mobilize Organize the community For action

Evaluate together

Explore the common issue & Set priorities

Act together

Plan together

Delegated power

Placation

Consultation

Informing

Therapy

Manipulation

Citizen control

PartnershipDegree of citizen power

Degree of tokenism

Non participation

Original Arnstein's ladder of participation

1.Manipulation and 2.Therapy1. Both are non participative. 2. Aim is to cure or educate the patients. 3. The proposed plan is best and the role of

participation is to achieve public support by public relations.

3. Informing4. A most important first step to legitimate

participation. 5. Too frequently the emphasis is on one way

information. There is no feedback.

4.Consultation Attitude surveys ,neighborhood meetings and

public surveys. Arnstein feels still this as a window dressing trial.5.Placation Allows the citizens to advise plan but retains the

power holders the right to judge the legitimacy or feasibility of the advice.

6.Partnership Power is in fact redistributed between the citizens

and the power holders. planning and decision making responsibilities are shared.

7. Delegated power1. Citizens holding a clear majority of posts in

committees with delegated power to make decisions.

2. Public now has the power to assure accountability of the programmed to them.

8. Citizen control Handles the entire job of planning, policy making

and managing the programmed.

How can you build community participation “community mobilization”

A process whereby a group of people become aware of a shared concern or common need and decide to take action in order to create shared benefits.

ACTION PLAN

• Steps taken to meet the health needs of the community based on the resources available and the wishes of the people (felt need).

PARTICIPATORY RURAL APPRAISAL

PRA is “a family of approaches and methods to enable local (rural or urban) people to express, share, enhance, and analyze their knowledge of life and conditions, to plan and to act.”

PRA• Participatory Rural Appraisal is a

methodology for interacting with villagers/community, understanding them and learning from them.

• It shifts the initiative from outsider to villager.

• PRA seeks to empower. It empowers the weak, the powerless and the marginalized, by enabling them to analyze, discuss and deliberate on their condition.

• Believes in flexibility in choosing methods.• Reversal of learning.

PRA Techniques / Tools

1. Village mapping2. Transect walks 3. Mobility mapping4. Seasonal Diagram5. Matrix scoring and ranking6. Trend analysis 7. Venn Diagram8. Daily activity Chart9. Force Field Analysis10.Causal Impact Diagram11.All undertaken by local people.

PARTICIPATORY LEARNING AND ACTION (PLA)

1. Approach for learning about and engaging with communities.

2. Combines an ever-growing toolkit of participatory and visual methods with natural interviewing techniques.

3. Intended to facilitate a process of collective analysis and learning.

4. The approach can be used in identifying needs, planning, monitoring or evaluating projects and programmes.

PROBLEM TREE

PRA Techniques / Tools

1. Participatory mapping or modeling

2. Transect Walks/Group Walk

To observe, to listen, to identify different zones or conditions, ask relevant questions to identify solutions

MOBILITY MAPPING

Explore the movement pattern of an individual, a group or a community.

Seasonal calendar

1) drawn by villagers with locally available materials

2) Depicting Local language months, seasons

3) Festivals/ social events, crops grown

4) Occupation / income generation

5) Periods of plenty/ scarcity6) Common diseases

Daily Activity chart

1. illustrates the different kinds of activities carried out in one day.

2. Time management - Effective utilization of time

3. To look at relative work-loads in different groups.4. How is his or her time spent?5. Period of relaxation, recreation, physical activity,

Personal care, rest.6. Income generation, productive work, community work 7. Whether women spend more time in collecting water

and firewood?

Daily Activity chart

VENN DIAGRAM

1. To know the individual and institutional linkages and relationships with the community.

2. Visual depiction of key institutions, organisations and individuals active in the community, responsible for taking decisions.

3. Degree of contact between them in decision-making4. Size of circle – importance5. Degree of overlap – Degree of contact

FLOW DIAGRAMSCAUSAL AND IMPACT DIAGRAMS

1. To identify the causal factors of health problems2. The various impacts of diseases, as perceived by the

villagers.3. Planning and evaluation tool.

Trend analysis• Attempts to study people’s account of the past of

how things that were closer to them have changed at different points of time.

• A useful tool for monitoring and evaluating a project.

PAIR WISE RANKING

• Compares pairs of elements, such as the preference for needs, problems, etc.

• Leads to analysis of the decision making rationale.

IMPACT / MATRIX RANKING AND SCORING • To rank the problems in the community based on

the intensity, the need for immediate or late action.

• Helps to prioritise the problems and needs.

Force field analysis

• Developed by Kurt Lewin• Technique to visually identify and analyze forces

affecting a problem situation so as to plan a positive change.

PROCESS OF COMMUNITY PARTICIPATION IN HEALTH PROGRAMMES

Analysis of the needs and requirements of the people in the community

Designing the primary health program to meet the needs of the people with the involvement of the people.

Educating the people through formal and informal channels to make them aware of the program and utilizing the resources available with them

Kindling and generating interest among people to keep up the momentum through the provision of resources not available locally.

Leaving the program to the care of the people with aided guidance

Contd..Providing aided guidance to handover the programme to the people

Occasional follow up to sort out any problem

Birth of a permanent community managed PHC

Birth of a healthy society

RECOGNISING THE CRISIS IN INDIA

Accessibility ?

Affordability?

PANCHAYATI RAJ

1. Balwant Rai Mehta committee (1957) 2. Started in 1959:by 1964 in whole India3. “An interconnected system of democratic

institutions at the village, block, and district level”.

4. 73rd and 74th constitutional amendment act 1992 made health and family welfare and education responsibility of village Panchayats.

THE COMMUNITY HEALTH VOLUNTEER SCHEME

THE NATIONAL PLANNING COMMITTEE 1946: Planned to train young men from the villages for 9 month in simple curative care and hygiene for PHS at village level.

Program was withdrawn in 1951 .Voluntary agencies picked idea in 1960 and 1970, and used

auxiliary personnel for the delivery of primary health care. Successes of it received international recognition and

together with the China example of “barefoot” doctors served as role models for the Indian government

Contd…

In 1977, govt. again adopted the approach but & one doctor/PHC for training purposes(BJP GOVT).

New govt. renamed the programme in Community Health Volunteers .(INC)

THE INTEGRATED CHILD DEVELOPMENT SERVICE SCHEME,1975

1. Community-based.2. Local woman is selected and trained for three

month to become the Anganwadi worker.3. Covers a population of 1000. 4. Anganwadi center she prepares and distributes

food, maintains growth charts, weighs children and gives non-formal education to the beneficiaries.

5. Also cooperates with the Primary Health Centre staff for health check up, immunization and referral.

COMMUNITY PARTICIPATION IN NATIONAL FAMILY WELFARE PROGRAM- MAHILA

SWASTHYA SANGHS• Constituted in 1990-1991• Consists of 15 women , 10 representing the varied social

segments in the community.• Total no of MSS: 79512, Budget allocation: 1200/year• Five functionaries involved in women's welfare activities at

village level:1. Adult Education Instructor2. Anganwadi Worker3. Primary School Teacher4. Mahila Mukhya Sevika5. Auxiliary Nurse Midwife(ANM)

VILLAGE HEALTH AND SANITATION COMMITTEE (VHSC)

Formed at the level of the revenue village (more than one such villages may come under a single Gram Panchayat).

Consist of:

Gram Panchayat members ASHA, Anganwadi worker , ANM Village representative of any Community based

organization

• CHAIRPERSON : Panchayat member (preferably woman or SC or ST candidate)

• CONVENOR ASHA if anganwadi worker not there

PHC Monitoring and PlanningCommittee

Committee monitors the functioning of Sub-centers operating under jurisdiction of the PHC and develops PHC health plan after consolidating the village health plans.

Block monitoring and planning committeeCommittee monitors the progress made at the PHC level

health facilities in the block, including CHC and develops annual action plan for the Block after consolidating PHS level health plans.

ROGI KALYAN SAMITI (RKS) /PATIENT WELFARE COMMITTEE/HOSPITAL MANAGEMENT

COMMITTEE (HMC) .Bring in the community ownership in running of rural hospitals

and health centers, which will in turn make them accountable and responsible.

RKS would be a registered society.• It may consists of:• Group of users: people from community Panchayati Raj

representative• NGOs• Health professionals

• A/C IPHS, it is mandatory for every CHC to have “Rogi Kalyan Samiti” to ensure accountability.

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COMMUNITY PARTICIPATION IN NRHM

INDIA’S COMMUNITY PARTICIPATION LAW: THE MODEL NAGARA RAJ BILL, 2008

1. India’s first community participation legislation and creates a new tier of decision making in each municipality called the Area Sabha.

2. Mandatory reform under the Jawaharlal Nehru National Urban Renewal Mission (JNNURM), which means that the various states in India must enact a community participation law to be eligible for funds under the JNNURM program.

3. Crucial because the Bill has the potential to empower people by ensuring regular citizen participation in decision-making that affects the conditions of their lives.

Swachh Bharat Mission (SBM)

1. Started as Central Rural Sanitation Programme (CRSP) in 1986.

2. With objective of improving the quality of life of the rural people and also to provide privacy and dignity to women.

3. With broader concept of sanitation, CRSP adopted a “demand driven” approach with the name “Total Sanitation Campaign” (TSC) with effect from 1999.

1. Implemented with focus on community-led and people cantered initiatives.

2. Encouraged by the success of “Nirmal Gram Purashkar” (NGP), the TSC is being renamed as “Nirmal Bharat Abhiyan” (NBA).

3. Swachh Bharat Mission (SBM) 2014: covers the entire community for saturated outcomes with a view to create Nirmal Gram Panchayats with:

Individual Household Latrine (IHHL) of both Below Poverty Line (BPL) and Identified Above Poverty Line (APL) households within a Gram Panchayat (GP).

SUCCESSFUL INDIAN EXPERIENCES1. Vadu Rural Health Project (Maharashtra)2. Comprehensive Rural Health Project, Jamkhed

(Maharashtra)3. Holistic Modality of Participatory Interface Mechanism

for Integrated Health Care in Rural West Bengal, Institute of Child Health, Calcutta

4. The Tilonia Model as a New Approach for Cooperative Development, Tilonia, Rajasthan

5. Sewa rural (Gujarat)6. Participatory health communication and action

(Madhya Pradesh)

QUALITATIVE ANALYSIS OF COMMUNITY PARTICIPATION

How much does the community know about the programme?

How much do they know about the organization carrying out the programme?

How often do they come face to face with the programme Personnel ?

What responsibilities do they carry out on behalf of the programme? What kinds of difficulties do they find in undertaking

these responsibilities?

Contd..

How satisfied are they with the involvement in the programme and why?

Do they have any suggestions to improve their participation in the programme?

Are all sections of the community equally involved in the programme?

If there is a differential advantage to some group, why does it happen and who gets the preferential advantage?

OBSTACLES TO COMMUNITY PARTICIPATION

Absence of confidence and ability of people in the machinery of health administration.

Unequal domination of power relations in favour of rich and to the disadvantage of the poorer sections of the society.

Inaccessible services in right quantity and qualityRigid bureaucratic set up impeding the people to

participate.Legal hurdles

Participation does not occur automatically. It is a process. It involves time. Hence it may lead to delayed start of a project.

1. Diverse interests and priorities due to social stratification

2. Resistance to decentralization and distribution of benefits

3. Failure to reorient entire health services to primary health care approach

4. Difficulty in mobilizing uninvolved populations5. Problems of maintaining sustained efforts

OBSTACLES TO COMMUNITY PARTICIPATION

PRINCIPLES TO RESOLVE THE OBSTACLES

• Channelizing the NGO’s to promote health plans • Effective training of Health personnel in Appropriate

technology• Responsive administration

• Openness in the sense of having wide contact with the people• A sense of justice, fair play and impartiality in dealing with men

and matters.• Sensitivity and responsiveness to the urges, feeling and aspirations

of the common man.• Securing the honor and dignity of the human being ,however

humble s/he might be.• Easy accessibility.• Honesty and integrity in thought and action.

Contd…

Inadequate understanding of local talent, abilities and resources.

Absence of identity with the community among people.People’s dependence on GOVERNMENT and not on their

selfHeterogeneity of interestsResistance to empower peopleResistance on the part of certain segment of population

to participateSustained efforts missing

Contd..• Effective public relations

• Spread of awareness about the health activities of the government with the expectations and aspirations of the people.• Speedy redressal of public grievances through

a systematic and well thought out mechanism.

• Sound health system• Empowerment of the poor• Developing social networks

DISADVANTAGES OF COMMUNITY PARTICIPATION

1. Participation does not occur automatically. It is a process. It involves time. Hence it may lead to delayed start of a project.

2. In a bottom-up participation process, we have to move along the path decided by the local people. This entails an increased requirement of material as well as human resources.

3. Participation leads to decentralization of power. People at the top should be ready and willing to share power with the people.

4. Participation sometimes develop dependency syndrome.

5. Participation can result in shifting of the burden into the poor.