One would be hard-pressed to find an article that does not emphasize the importance of community participation for the success of Community Health Education Promoter. However, there is much less clarity about the exact meaning and purpose of “Community Participation”. It carries with it a number of different underlying distinguished between community participation as the mobilization of community resources (people, money, materials) to carry out health programs versus community participation as increasing “people’s control over the social, economic and environmental factors determining their health. It is nevertheless widely acknowledged that a considerable gulf exists between the ideal of programs driven and owned by communities and program realities. It is further agreed that while there are few success stories of lasting community participation, the sustainability and impact of programs require the ownership and active participation of communities as a non-negotiable pre-condition. This appears to be easier to achieve in small-scale programs initiated within and by communities, often with assistance from an NGO or a church group. There is also experience that active participation of communities in health and social action, including Community Health Education Promoter, is more likely to occur and be sustained in conditions of popular mobilization, such as in the aftermath of a liberation struggle or after the replacement of military or repressive regimes by popular governments.
In most of these, cases substantial and time-consuming investments were made in: (1) Securing participation of communities and (2) Involving them in all aspects of the program, including the identification of priorities and project planning. In other words, community mobilization precedes and accompanies the establishment of Community Health Education Promoter programs. One of the most important conditions for sustainability is the capacity of the community members for organizing themselves. And it is perhaps one of the most important achievements of program that the local people had been mobilized in such a way that they were able to carry on solving their own problems and securing the health services that they wanted.
Right from the beginning, the project staff encouraged representative groups to identify and prioritize their needs, to contribute money for the construction and maintenance of water points and other facilities, and to select their own health workers. It is crucial for the continuation of the project’s work that, in both, committees have been formed to coordinate the efforts of the volunteers, to secure support of the Health Authorities, donors and NGOs engaged in health care and health education, to promote the training of Community Health Education Promoter.
National or state-wide programs are usually initiated from the center. While in these cases, too, community participation is explicitly part of the agenda, for a number of reasons it is much more difficult to achieve. The key reason is that “community participation has been conceived in a paradigm which views community participation as a magic bullet to solve problems rooted both in health and political power. For this reason, it is necessary to use a different paradigm which views community participation as an iterative learning process allowing for a more eclectic approach to be taken. Viewing community participation in this way will enable more realistic expectations to be made”. The community capacity building increases community participation, which in turn leads to increased support for Community Health Education Promoter.
Evidence also seems to suggest that problems arise when Community Health Education Promoters are expected to take responsibility for mobilizing communities, rather than working with the support of already active communities. If Community Health Education Promoter is high level of knowledge, higher levels of community organization were associated with community impact. Surprisingly, neither the demographic characteristics of the Community Health Education Promoter nor his/her level of competence affected the impact of the program on the community. Where community participation is institutionalized, it is usually through village health committees (VHCs), known often by different names, which are charged with managing and guiding the work of Community Health Education Promoters. But VHCs also play an ambiguous role within Community Health Education Promoters initiatives. The position of VHCs within village hierarchies is not always clear and is often contested, leading to tensions between VHC members and other community leaders or becoming the site of political contestation.
The character, role and organization of community participation in health care in general and in the running of Community Health Education Promoters in particular form an immensely complex and contested area with a vast literature of its own. This section barely scratches the surface of this rich debate.
Emoticon Emoticon