Community Health (1) - Community Health Study Pack

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

S TU D Y P A CK FO R CO MM U NI T Y DE V EL O P ME NT WO R K ER S
AUTHOR: EDITOR:
Tine Jaeger - Technical Response Team 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 for permitting Tearfund to represent their programmes in this manner. We would also like to acknowledge the contributions and comments of Dr Simon Batchelor, community development consultant and Mrs Muriel Chowdhury, community health consultant.
February 1999
REF LECTI ON AN D LEA RNING FOR GOOD DEVEL OPMEN T PRA CTICE
Contents
Illustrations Index
page 3
Section One
Who is this case study for? How to use the pack What is community health development? - An overview
page 5 page 6 pages 7-11
Section Two
ABCD Overview of the programme
Clear vision, objectives and activities - principle 1 Partnership with donors - principle 13 page 13 page 14 page 15 pages 16-17 page 18 page 19 pages 20-21 page 22 page 23 pages 24-25 pages 26-27 page 28 page 29 page 30 page 31 page 32 page 33
ASHA Overview of the programme

Community ownership - principle 3 Skilled leadership - principle 7 Appropriate activities - principle 8 Partnership with local and national government - principle 11 Partnership with national/international non-government and community organisations - principle 12
JAMKHED Overview of the programme

Focus on the poor - principle 2 Sharing of skills to support the development of communities - principle 4 Resource mobilisation - principle 5 Skilled, committed and motivated facilitators - principle 6 Efficient monitoring mechanisms and evaluation framework - principle 9 Secondary health referral - principle 10
CONCLUSION
Section Three
Comments on discussion questions Studying in small groups
Evaluation of non-medical aspects of community health development
pages 35-43 page 44 page 45 page 46 pages 47-50 page 51 page 52 page 53
Action plans Guidelines for good practice in community health development Glossary Abbreviations Recommended reading and references
Illustrations Index
Fig1 Fig2 Fig3 Fig4 Fig5 Fig6 Fig7 Fig8 Fig9 What is Community Health Development? Historical time line of community health programmes WHO - range of primary health care activities Deprivation trap Spectrum of community health programmes Diagrammatic representation of community health development Village in Prey Veng Village development committee Ekta Vihar slum colony page 5 page 7 page 8 page 8 page 10 page 10 page 13 page 14 page 16 page 19 page 20 page 22 page 25 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32
Fig10 Dr Kiran Martin with women from Ekta Vihar Fig11 Community health volunteer with a mother and child Fig12 Co-operating with the authorities Fig13 Graph showing decrease in malnutrition rate Fig14 Graph showing increase in immunisation rate Fig15 A) Diagrammatic map showing how dalits are not included in Ghodegaon Village B) Diagrammatic map showing how dalits are now included in Ghodegaon Village Fig16 Village health worker with village women Fig17 Villagers working together to conserve water Fig18 Moses fitting a limb Fig19 Villager in Ghodegaon explaining their statistics on the board Fig20 The Two Mules - Everyone benefits when hospitals and primary health programmes work together
Section One
Section One
Who is this case study for? How to use the pack What is community health development? - An overview
Fig1 What is community health development?

Crooks Bill, 1999, Tearfund
Community health development (CHD)

is an approach to working with communities at grass-root levels. Programmes which implement CHD start with a clear goal or vision of bringing lasting changes towards full health in peoples lives, especially the poorest. This is achieved by strengthening peoples sense of their own value and ability to make choices 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 into principles 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.
Purpose
To provide an opportunity for reflection and learning through the study of three programmes that demonstrate 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 to implement community health development programmes, but section three includes suggestions for further reading.
Learning Objectives
1. 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 the questions and taking part in the activities.
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How to use the pack

We believe everything in this pack is worth reading. You can just read through the pack and not bother with the study sections. However, we do, of course, recommend that you do take time to reflect and learn using the questions and activities. We hope that you will benefit from using the study material in the pack either on your own or as a group, although we believe that being able to work with others will increase your opportunities to learn (see Studying in small groups in section three page 44). STEP ONE Read the overview discussion of community health development (section one pages 7 to 11). This will provide the relevant background information to the different case studies and how they demonstrate good practice in community health development. STEP TWO Before reading the individual case studies in-depth you might find it helpful to read quickly through the whole of Section 2. This will help you to gain more from the case studies. A second or even a third read will enable you to pick up more details than you can on just one read. It is suggested that Section 2 is read together with the Guidelines for good practice in community health development in section three, pages 47 to 50. STEP THREE Read each study carefully and begin to think and take notes about anything that you find interesting, new or similar to your own experience. STEP FOUR When you have read the individual case study and taken notes, read the questions and activities carefully. Dont rush into answering the questions, take time to think and then write down your thoughts and ideas. If you are working as a group, spend at least 5 minutes thinking on your own before starting to share and discuss your answers (remember section three will give you useful advice on studying in small groups). Sharing your ideas and thoughts with others often increases your own understanding and makes ideas clearer. STEP FIVE Before reading the final summary and conclusion (page 33) in the pack you may find it helpful to write down your own summary of what you have learnt either on your own or as a group. STEP SIX Read the final summary and conclusion (page 33) and compare it to your own ideas about community health development now that you have finished the studies. Once you have reached this stage you might want to begin to think about a plan for putting some or all of these principles into practice in your own situation. There are further questions at the end of this section that should help guide you in this (See Action Plans in section three page 46.) We have also suggested some other activities that will provide further opportunity for reflection. STEP SEVEN The support material in section three called comments on discussion questions, pages 35 to 43, is information that adds to the case studies. The authors have given their comments concerning the questions accompanying the individual case studies. To gain full benefit from the pack, we suggest you read this section after you have completed all the case studies and study sections.
STEP ONE
Read overview in Section One
STEP TWO
Read all Section Two once
STEP THREE
Think & take notes on each study
STEP FOUR
Work together to answer the questions
STEP FIVE
Write down the main points youve learnt
STEP SIX
Write an action plan. Take part in 2 more activities
STEP SEVEN
Read and check your answers
Finally, we hope you will enjoy this case study pack. Tearfund has produced two other similar study
packs concerning principles of good practice in HIV/AIDS and Child Development. 6
What is community health development?

Q From your own experience what do you believe community health development to be? Q Whats the difference between health, sickness, medicine, disease & well-being ?
Health vs medicine
In some ways CHD is a new approach and it is certainly very different to much practice in community health programmes. The latter tend to focus on preventive medicine. It is important, therefore, to distinguish between medicine and health. Medicine looks primarily at preserving and restoring the human body and mind to health. Health, however, is much broader than just the absence of disease. It concerns well-being in every area of life: physical, mental, emotional, spiritual, economic and social, and recognises that they are all inter-related. So, we can speak not just of healthy individuals but also of healthy communities. This distinction can be further explored by reading chapters 1-4, especially pages 13-19, 30-37 and 54-58 in Primary Health Care - Medicine in its place by John MacDonald.
Origins of community health programmes

Traditionally, community health programmes grew out of recognition that hospitals and highly qualified professionals (for example, doctors) were not the answer to ill health. In the last 75 years, life expectancy in the west has increased by at least 20 years. We have seen that the population grew healthier because of improvements in living standards through provision of better housing, sanitation, clean water and improved nutrition. All these were achieved without the discovery and use of antibiotics or advanced modern medical technology. Similarly in developing countries, up to 90% of poor physical health is due to diarrhoea, chest infections, malnutrition and easily preventable infectious diseases. All of these can be dealt with using low technology solutions such as clean water, oral rehydration solutions, cheap antibiotics and immunisations. To implement these solutions, community health programmes generally train village level health workers to undertake a range of activities. These services may include growth monitoring, immunisations, midwifery care, basic first aid using simple treatments, health education and house to house visits to detect illness and refer patients.
Draw a time line showing when different health care activities were started in your programme or one that you know. What were the objectives for these activities and were they achieved? (e.g., see figure two below)
1920
Mission Hospital
1950
Mass immunisation campaign
1970
Mother & child health mobile clinics
1980
Training of TBAs & VHWs
Fig2 Time line
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The WHO defined a range of Primary Health Care activities (Figure three): Nutrition
Immunisation
Antenatal Care
Clean Water
Essential Drugs
Sanitation nn
Fig3
Health Education Access to secondary referral
Problems with the general approach to community health

Q What do you think the main limitations of community health programmes are ?
Over the years, programme implementors have realised that there are many problems with this approach. Firstly, it often fails to touch the lives of the poorest. For example, very poor women are often unable to benefit from the services because they need to work at clinic times, live too far away, never hear about them or mistrust the health workers. The programmes generally fail to challenge the low status given to certain groups such as women and the very poor. Furthermore, those who do become involved in the programme often do so only on the level of passively receiving services. They learn to obey the system. Subsequently they may change some of their behaviour, for example by using a pit latrine, which is helpful in improving health; however, the complex results of poverty remain unaffected leaving people still vulnerable to chronic illhealth. People are caught in a deprivation trap (see figure four below). This figure is further explained in the book, Rural Development pages 111-114, R. Chambers.
Fig4 deprivation trap from Chambers R,

1993, Rural Development, Putting the last first, Longman, page 112
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In recognition that much disease is poverty-related, many community health programmes have added micro-finance activities with the aim of improving economic status, especially of women. Sadly, even if women gain some small extra financial means, their status is often unchanged and they remain marginalised. It has also been notoriously difficult to sustain the main practitioners in the programmes: the community health workers. Difficulties include ensuring regular support and skillsupgrading, maintaining motivation and deciding on remuneration and incentives. The community health workers may be exploited by decisionmakers who see them as a cheap alternative to doctors and hospitals. Also, these workers may end up seeing themselves as belonging more to the programme than to their communities and may adopt a superior attitude to the other villagers. Another problem is that different health issues are often divided into different specialisms. This leads to a sectoral approach with a number of separate (vertical) programmes addressing different issues such as TB, leprosy, AIDS, nutrition, water and sanitation. Often there is very little communication between the different sectors. Sometimes separate departments are formed in the same location, for example, one for community health and another for development. Since health covers all aspects of life, this separation is illogical and unhelpful. Some of the health indicators that programmes seek to improve, are often not significantly changed even after many years of programme activity. For instance, while community health programmes may bring significant increases in levels of immunisation coverage and consequent decreases in morbidity and mortality from such diseases as measles and polio, many programmes continue to report high incidences of diarrhoeal and respiratory illness even after 10 or 20 years of work in the villages. This is because basic problems such as poor water and food supplies and inadequate housing have not been addressed.
A development approach to community health

Q What does the phrase a development approach mean to you? Q List from your own experience the main aspects of this approach
Programme staff have discovered that, for community health programmes to bring lasting change in peoples lives, a development approach must be adopted. Amongst other things, this means: time given to relationship-building, communities encouraged to organise themselves so they have a voice, emphasis placed on building the ability of individuals and the communitys capacity to care for themselves, and all people valued and respected. Any initiative is based on the villagers priorities and they are encouraged to find their own solutions to issues which they have identified as important. If people are hungry and do not have good water to drink, they will not be interested in disease prevention. So it is important to start with the peoples concerns. Development is total change: not just health in a narrow physical sense, but social, economic, moral, environmental and spiritual. A key feature in communities taking charge of their lives is the formation and development of a small group of village representatives. These may be womens groups or farmers clubs or youth groups. It is recognised that individual communities may contain many different groupings and, as far as possible, all should be represented so that everyone has the chance to be heard. In the words of an Indian villager: a good community health programme makes sustainability sure. Once individual people and the village where they live have got selfrespect and control over their lives, there can be no going back . In the end, sustainability is what people can do for themselves; project staff were a means 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 is made in the image of God; every man, woman and child is valuable and has potential; as a person changes within, so he can change his situation; personal development is more important than economic, and development of human capacity to care for others is essential. This means, for example, that poor people are empowered to become healthier and gain choice and control over their lives, not in order to dominate but to co-operate. Interdependence will involve people being able to approach the authorities in both confidence and humility. It also means that project activities should promote Christian values. So, for example, while emphasis is placed on supporting people in taking initiatives, these activities should not disadvantage vulnerable groups such as women or children. 9
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The diagram below (Figure five) describes the spectrum of community health programmes:
Conventional community health Goal: decreased maternal/infant mortality, morbidity etc. Focus: programmes, activities Agenda set by organisation Fixed interventions; often limited to MCH + water & sanitation Generally not sustainable changes in community often do not last if programme stops Poorest of the poor often remain excluded Values often remain unchanged
Community health development Goal: self-reliant healthy communities 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
Fig5 Chowdhury M, 1997
Most programmes will fall between the two types represented here. Some programmes are likely to have a strong community health development focus in some aspects of their work while remaining conventional in others.
Tearfund Community Health Development Guidelines

If you havent already done so, please read the Community Health Development Guidelines pages 47 to 50. The document included in this pack (pages 47 to 50) which is called the Guidelines for Good Practice in Community Health Development outlines 13 key principles. We believe these are necessary for community health development programmes to be effective and sustainable. The guidelines resulted from a period of research which included a 0review of current literature, visits to other agencies, questionnaire surveys of partners and consultants and visits to projects in Latin America and Asia. Because of the importance of using a development approach in the implementation of community health, Tearfund has decided to speak of Community Health Development. As the key principles are much inter-related, there is inevitably some overlap of issues. For example, community organisation appears in both principle 3, Ownership by the community and in principle 8, Appropriate activities. Below is a diagrammatic representation of the 13 principles (Figure six).
Fig6
The case studies in this pack outline three community health development programmes. They all happen to be located in Asia because of the authors familiarity with this region. However, there are examples of good practice in other regions and it is hoped to add further studies from other areas at a later date. The case studies do not attempt to describe the whole of each project; rather they show a small glimpse of how each one demonstrates some of the core principles of community health development and how this has brought long-term changes in peoples lives. Likewise the fact that only a few of the principles are described for each project does not mean that the project only demonstrates these and not the others, but that focus was made on just a few elements in each case. As two of the projects (ASHA and Jamkhed) are much older than the third, ABCD, rather more of the principles are covered by the first two. 10
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Unfortunately, there is much jargon associated with development. Terms like participation bring confusion by being freely used to mean many different levels of community involvement. Others, like praxis, mean nothing to people unfamiliar with a certain area of development language. A glossary of terms 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 demonstrating successful practice but each of the projects has been subject to struggles common to project implementors everywhere. 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 own context.
2.
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.
Tearfunds learning materials and case studies may be adapted and reproduced for use provided the materials are distributed free of charge. Full reference should be given to Tearfund and the relevant authors within the materials.
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Section Two
Section Two
Clear vision, objectives and activities - principle 1 Partnership with donors - principle 13

Community ownership - principle 3 Skilled leadership - principle 7 Appropriate activities - principle 8 Partnership with local and national government - principle 11 Partnership with national/international non-government and community organisations - principle 12
JAMKHED Overview of the programme

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

Learning Objectives
The specific learning objectives for this study are to enable the reader to understand and describe 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 and Community Development) programme is based in three rural communities (22,000 people) in Cambodia. The focus of the programme is transformation of people and their ability to manage change. All the physical changes (credit schemes, water pump programme, agriculture etc.) made by the community are only tools that help them develop their ability to think, analyse and find solutions and to be proactive towards change. In practice, the programme does not depend on a formula method of working but on relationships. The programme is implemented by western NGO, Christian Outreach, who began running a primary health care programme in the province in 1990. During a village health survey, the villagers asked for help in solving a wide range of problems beyond health. They recognised the cause and effect of poor water supplies and inadequate food on their general well-being and especially that of their children. Following recommendations from a period of research and a pilot programme, a planned 7 year programme began in 1994. The entry point for beginning a programme in a village comes with the villagers being carefully encouraged to begin to discuss their problems (animation). A priority need and the action to be taken is agreed by the villagers and Christian Outreach. Whatever they suggest is followed, depending only on the cost, and no value judgement is made by the outsiders. The aim is to communicate that decisions rest with the people and not with the outsiders. Even if this small trust-building exercise fails, it still provides a discussion point for developing ability in critical analysis. At the first meeting, a Village Development Committee (VDC) of five to seven people is chosen by the villagers. The committee meets with the programme animator to discuss all aspects of life. The meetings are open to everyone to help keep decisionmaking accountable to the wider community. In addition, the animators take walkabouts in the village. At these times, the animators form relationships and ask questions to develop peoples thinking. After much discussion, the community decides together on actions that will improve the quality of life for the poor. In the early months, the animators only ask questions. They do not give information or offer ideas until the villagers have confidence in their own knowledge and experience and the relationship is strong enough for them to be able to disagree with the animators. The programme recognises three levels of information important for community development: 1. Information in the community (but not 13 necessarily shared): During the first six months, the animators questions should be drawing out the information that exists in the community but is not necessarily discussed during everyday life. Sharing this information can bring benefit to others in the community. 2. Information within reach: There is information that is not in the community but is within its reach. An example of this might be the price of a hand pump for sale in the local market. The animator encourages the community to find out this kind of information for themselves.
3. Information beyond reach: discussion leads the group to seek information from the animator which is shared once the relationship is strong enough for dependency to be avoided.1
Fig7 Village in Prey Veng Jaeger M C, 1997, Tearfund
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Clear vision, objectives and activities - principle 1
Q Think of your own programme or one you know. What is its vision or goal?
The ABCD programme started with a clear vision or goal to increase peoples ability to initiate change and make choices in an environment of loving relationships. The goal can be considered a guiding light to the programme for its philosophy, principles and methodology. It shows the way towards the wider objectives: 1. Alleviation of extreme rural poverty in Prey Veng district 2. Alleviation of feelings of war trauma, isolation, fear and being violated 3. Sustainable replication of the programme. The programme works towards the wider objectives by fulfilling its immediate objectives: 1. Animated people who will make benevolent changes in their physical environment and health after external inputs have come to an end. 2. A healing environment which breaks down barriers of fear, isolation and the sense of having been violated. 3. Improvements in the physical environment and health of three communes made through participatory process. 4. 5. Replication of the programme by a Cambodian organisation. Enterprises that create income for the participants with particular reference to assisting vulnerable groups. towards the goal. For example, ABCD has decided on indicators such as: Each of the 25 village development committees to have 5 meetings within the last two years 20 development funds managed through three financial cycles with emphasis on vulnerable groups More than six clinics held in each commune every three months without external initiation.
The wider objectives are not expected to be fulfilled within the life of the programme, whereas the immediate objectives should be in place by the end of the programme. Having identified the desired objectives, the planners define what activities need to be completed (outputs) in order to achieve these objectives. Examples of activities to be completed include: 25 village development committees established 25 development funds in operation and managed by the villagers Regular antenatal care available in all three communes There is a clear link between the goal, its objectives and its activities. The goal is the plumbline against which actions in the programme are measured. Indicators of achievement give the staff the means to measure whether or not they are moving
Fig8 Village development committee

Jaeger M C, 1998, Tearfund
ABCD is strengthened by having a clearly stated vision with identification of how this is translated into objectives and outputs. The programme retains flexibility so that objectives can be adapted as the situation changes.
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 the start of a programme may need to change? 3. Does your project have clear vision, objectives and activities? Are they clearly linked and regularly reviewed?
If YES, how have they changed as the programme has developed? How much is the community involved in deciding on the objectives and activities? If NO, what plan could you make to decide on setting your programmes goal, objectives and activities more clearly?
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Partnership with donor agencies- principle 13
Q What does partnership mean to you?
ABCD is funded by both Western government aid and NGOs. The funding is constructed in such a way that it is not tied to the agenda of an outside agency. It is flexible allowing the agenda to be set by the people. Space is left for the people to work within their own decisions and at their own pace without threatening the responsibility of Christian Outreach to their donors. The willingness of the agencies to enter into a 5 year funding commitment is due at least in part to the clear objectives, activities and measurable indicators set out at the start of the programme. Also regular reports with clear explanations for changes in plan, have kept the donors informed of project progress. The hands-off approach of ABCD may seem to be risking a lot of money as the villagers could decide on interventions which are inappropriate. However, the ABCD experience has shown that, as long as the process does not become trapped in power structures (for example, not all decisions should be made by the commune leader), the decisions will be relevant. The decisions made are transparent and represent the majority of the village. In practice, the programme has found that this approach has resulted in less money being used and wasted than with comparative paternalistic interventions where discussion is not encouraged. The donors have recognised that good development practice means that programmes must start small and take time to build relationships. Willingness to fund the programme has grown from a relationship of trust between Christian Outreach and the donors.
1. 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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Learning Objectives
The specific learning objectives for this study are to enable the reader to understand and describe 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 for Securing Health for All) is a community and development society working in the slums of Delhi. Delhi has a total population of 13 million and there are 1500 slums with a population of 3.5 million people living in makeshift huts. Slums are characterised by enormous social problems. People come from states all over India and often only stay a short time in any one place. Slum dwellers often feel very insecure. They are occupying land illegally and demolition by the authorities can occur at any time. Therefore, they are often reluctant to invest money in improving their homes and environment. Most slums have no drinking water, sanitation or electricity. In addition to diseases associated with inadequate water and sanitation, slum dwellers are also at risk from illnesses linked to pollution and substance abuse. Also there are very few people of influence willing to speak on their behalf. ASHA was born out of a vision to love and serve the poor in the name and spirit of Christ. The work began in 1988 in one slum of 4000 people, and by 1998 it had grown to cover a population of about 165,000 people in 21 slums in various parts of the city. The overall objective of ASHA is to improve the quality of life of disadvantaged urban dwellers. ASHA builds trust and acceptance by offering subsidised curative clinics as its first initiative with a community. As trust is developed, staff are able to mobilise and train women health volunteers and traditional birth attendants. Further mobilisation occurs through womens action groups (Mahila Mandals), which discuss health and social issues. These groups increasingly become involved in improving the slums by their own direct action or lobbying civil services. Significant progress has been made in improving the quality of life. About 80% of children under five in project areas are now healthy and maternal health has also greatly improved. In areas where the project has worked longest, there is significantly less diarrhoeal and acute respiratory disease1 . All the slums in which ASHA now works have some form of community latrine and water supply. Also, drainage and refuse disposal have all been significantly improved. ASHA recognises that empowerment is a key issue and therefore seeks to ensure that this is the underlying basis of all its activities. The aspects which have made this a successful community health development programme include:
Fig 9 Ekta Vihar slum colony

Webb M, 1990, Tearfund
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Its holistic multi-sectoral approach (see Appropriate activities, principle 8) Working at the invitation of slum communities Working with the government, both to obtain services and resources and to lobby for change Developing good relationships with slum-lords (politically controlled individuals who control the slum dwellers by extracting payments) Strong emphasis on empowerment and training local people with a particular emphasis on women Insistence on community contribution and participation - avoiding hand-outs Developing cost-effective and reproducible programmes As far as possible facilitating and empowering rather than providing. needs as an important integral part. An awareness of Gods love and concern for the poor is the motivation behind ASHAs work. Service, honesty, integrity and respect for all are at the heart of all programmes, regardless of caste, religious status, family or economic situation. In Dr Martins words: Our motivation to work among the poor in slum colonies comes from our devotion to Christ. We are consumed with our desire to bring about real change in peoples lives.....
Finally, the programme is underpinned by Christian values: health is viewed as a holistic concept, with spiritual
Infant death rate is 40 per 1000 (over 100 in other Delhi slums) Child mortality has fallen from 56 per 100 in 1988 to 8 per 100 in 1997
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Community ownership - principle 3
Q Why is it important that health programmes are owned by the people?
One of ASHAs key strategies is empowerment and development of human potential. In the outworking of this strategy, the slum-dwellers increasingly gain ownership of the programme. Community support is gained by ASHA in two main ways: firstly by calling people from the community to offer themselves to become trained as health volunteers. This aspect of the programme follows a fairly conventional model of community health. However, rather than being paid by ASHA, the health workers charge fees for service. This encourages accountability and involvement by the community and has been seen to work even in the poorest communities. Secondly, community involvement occurs through the formation of the womens action groups, the Mahila Mandals. In India, the basic laws are just but often poor people do not have the confidence or solidarity to access these rights. The Mahila Mandals give women the opportunity to voice their problems and work with neighbours to find solutions. They gain self confidence to speak out for themselves and have been considerably more effective in influencing sustainable health outcomes than the established slum health committees. 475 families in one slum formed a co-operative housing authority and were able to transform their slum into a community with proper roads, drainage, clean water, electricity, health centre, school, park and a clean environment. Another innovative feature of this initiative was to encourage women to hold the legal title to the new property in defence against abandonment by their husbands. The ongoing maintenance and management of the community is funded by the inhabitants via their housing co-operative. The people themselves have become agents of change. ASHA has found that active participation and ownership by the community requires much patience and persistence. It has identified a number of ways that community participation can be measured. For example: by seeing attitude changes, the quality of input in meetings, how often meetings are attended, and levels of independence such as whether people can access government services alone. In some slum areas, the work has been totally handed over and the communities are initiating their own changes. For example, many Mahila Mandals have gone to other areas to teach. There have also been a number of cases where neighbouring slums have taken action because they have seen the beneficial effects in the slums where the ASHA programme operates. These are all examples of how the programme seeks to give control or ownership of the activities to the community.
1. 2. What does community mean in the area where you work? 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?
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Skilled leadership - principle 7
Q In your experience, what are the differences between a good and a bad leader?
ASHA was founded by Dr Kiran Martin. Previously, she had worked for a short time in a health centre for slum dwellers. Here she saw the potential of a community-based approach and her Christian faith played a major part in her decision making. She approached the community and began to listen to them. She then sought the assistance of the authorities to provide a site for a health clinic. The director of the Delhi Slum Wing was initially sceptical of her approach but her persistence won through. His helpfulness now is due to the relationship built by Dr Martin. Dr Martins intuitive understanding of how to involve everyone through relationships has made the project succeed. Time and perseverance have led to strong working relationships with both the government and the slum landlords. This does not prevent Dr Martin from challenging wrong decisions or actions if necessary. Dr Martin demonstrates crosscultural understanding and practises principles of impartiality. She is able to identify with and relate to the poorest of the poor and in the next moment give attention to
Fig10 Dr Kiran Martin with women from Ekta Vihar
Jaeger M C, 1997, Tearfund
an important visiting official. 60% of her time is spent with the community. Her leadership style with ASHAs staff is one of friendly relationships. She is willing to spend time with both the management of the programme and the cleaner of the clinic. She has seen and developed the potential in untrained staff, regarding motivation and the right attitude as more important than appropriate professional qualifications. For example, two
key staff members previously worked as a beautician and teacher respectively. High quality support is especially important when staff lack formal education or professional skills. Slum work is difficult and team members have often been verbally and physically abused. Over the years, she has been able to pass on her vision to the staff. Her enthusiasm and dedication have been key in this ambitious and innovative programme.
1. Dr Martin did not start the programme with a proven track record of implementing successful community health development programmes. What do you think are the aspects of her leadership which have made the programme successful?
2. What qualities of leadership are necessary in your programme?
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2
Appropriate activities - principle 8
Q List the main activities in your programme. Describe how they enable your goal and activities to 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; environmental improvement; and the development of community and individual potential.
Community based Primary Health Care

Community Health Volunteers (CHV) are the women who form the backbone for most of the PHC work. Each CHV is responsible for providing promotive, preventive and some curative health for about 200-300 families in the area in which she lives. This includes making regular home visits, treating simple illnesses, referring to other services, promoting family planning, and health education. The government built the 15 slum clinics and continues to be responsible for their maintenance whilst ASHA staffs and runs them. Weekly general outpatient clinics are held by a doctor. Antenatal and underfives clinics are run by CHVs. Child health education and awareness-raising is also undertaken by the Mahila Mandals. ASHA works with the Ministry of Health in organising immunisation campaigns.
Fig11 Community health volunteer with a

mother and child Webb M, 1990, Tearfund
Environmental and Sanitary improvements

ASHA sees this as critical because of the importance of the environment to health, social and economic status. Despite the municipal authorities limited resources, all the slums in which ASHA works now have some form of community latrine. ASHA has also supported communities in negotiating for drainage channels, brick pavements and a municipal refuse disposal service. ASHA facilitates communities, usually through Mahila Mandals in pressing authorities for ongoing maintenance, repairs and supervising the quality of cleanliness. The Mahila Mandals have learnt to be strong protesters when services break down and to encourage communities to accept responsibility for achieving cleanliness in their own areas.
Empowerment and development of potential

ASHA believes that women, with their role in families and communities, are key in fighting poverty. Therefore ASHA seeks to empower women in the Mahila Mandals with participatory training and development. There are currently 36 active Mahila Mandals with a total membership of 930. Their activities include: - weekly meetings to discuss relevant community information and agree appropriate responses; systematic monitoring of the communitys health;- protesting together to slum leaders about social issues and injustices such as the misuse of resources and power;- lobbying municipal and government authorities to achieve services; - four Mahila Mandals run sewing centres where women pay to learn simple sewing skills; two run day time child care centres to enable women without family support to work;- working with another NGO to run small credit and savings schemes for income generating purposes. A longterm initiative relating to empowerment is weekly childrens clubs. This acknowledges the importance of children growing up aware and informed. There are a total of 36 clubs with a membership of 818.
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2
Training
Training is one of ASHAs key strategies and is at the heart of most of its interventions. Each clinic doctor runs regular training sessions for the ASHA staff and CHVs. Periodically, more formal programmes are held, for example to train new CHVs or educational focuses for Mahila Mandals. Sometimes training has been ongoing: for example, how to organise delegations to the government, how to write letters, how to record statistics and keep accounts etc. ASHA teaches by example and training is on a participatory basis. Most training is given by ASHA staff but ASHA also makes use of other relevant training courses run by the government and other NGOs.
1. Which of ASHAs activities would you consider to go beyond normal community 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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2
Partnership with local and national government - principle 11
Q List all the ways your community health programme works with the local & national government
ASHA works on the principles of acceptance and of authority not being intrinsically evil. This has allowed the project to work with the government to find solutions, rather than being confrontational over its weaknesses. In theory the government in India is committed to affordable health care for all. There are many laws for the protection of the weak but often these laws are abused by the people in authority. The law is not wrong; it is the use of the law that is corrupted. ASHA has taken the approach of working towards co-operation with the authorities. The local government has learnt to trust and respect ASHA and hence is willing to entrust them with their limited resources, knowing they will be well used. The government authorities have given many false promises in the past, but in its advocacy role, the project has been able to negotiate 23 buildings all paid for by the government. The relationship developed with Mr Singh, the commissioner for the Slum Wing, is key. He granted ASHA the site for the clinic. He also played a key role in organising the finance from the bank for upgrading the slum as well as organising the authorities to agree to the action. ASHA also works with the Slum
Fig12 Co-operation with the authorities S Batchelor, 1996, Transforming the slum by relationships, ASHA, Tearfund
Wing to organise housing loans at a low interest rate with the Oriental Bank of Commerce. Importantly, Dr Martin has been able to involve not just the relevant officials but also the unofficial officials, the slum landlords. The fact that ASHA is not trying to make money or achieve status and does not have underlying political motivations, means that the slum leaders have become more trusting and cooperative.
Difficulties with the relationship have arisen when politicians have given free distributions to win the votes of the people. This handout mentality is undermining. Also leaders have sometimes taken the credit for programme achievements such as the new water scheme. The Governments new housing policy has adopted the model developed by the Mahila Mandals who transformed their slum into an established community.
1. What difficulties do you experience in working with government organisations?
2. Make a plan to show how you could begin to improve this situation
bearing in mind ASHAs experiences.
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2
Partnership with national/international non-governmental and community organisations - principle 12
Q What are the positive and negative aspects of working in partnership with other NGOs and community organisations?
Where possible, ASHA works together with other organisations in the area. It works in cooperation with other NGOs to provide programmes such as vocational training, housing and micro-enterprise. For example, in the micro-enterprise programme, ASHA identifies the target group while the other organisation provides the teaching. Income generation through the banks did not work but has been successfully implemented through other NGOs. Only one other NGO is involved in health in one of the locations in which ASHA works, so there is little risk of duplication of services. However, problems have arisen over different salary policies. ASHA health volunteers are not paid and staff receive a relatively small salary, while some other NGOs have a different ethos, offering relatively high salaries. High salaries can create dependency and loss of ownership amongst slumdwellers as they are not able to pay for these workers. Also these differences can cause ASHA staff to leave to find higher salaries elsewhere.
1. 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 ways you 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 common with organisations involved in agriculture and income generation for instance.
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JAMKHED overview of the programme

Learning Objectives
The specific learning objectives for this study are to enable the reader to understand and describe the following key principles of community health development: 1. Focus on the poor - principle 2 2. Sharing of skills to support the development of communities - principle 4 3. Resource mobilisation - principle 5 4. Skilled, committed and motivated facilitators - principle 6 5. Efficient monitoring mechanisms and evaluation framework - principle 9 6. Secondary health referral - principle 10
Jamkhed Comprehensive Rural Health Project is situated approximately 250 miles east of Bombay, India. It is the story of people - of men and women outside the mainstream of society, who have gained the self-esteem and self-confidence necessary to determine their own lives. It is also the story of the development of a sustainable community-based primary health care programme in one of the poorest parts of India.... Poor illiterate men and women have shown that Health for All can indeed become a reality, if only the professionals would allow it to be so. (Arole R.& M, 1994) In 1970, Drs Raj and Mabelle Arole were invited by the leaders of Jamkhed, to provide health care to their community. Starting with simple curative care, the programme has spread to 175 villages touching the lives of about a quarter of a million people. Not only has it brought better health to the people, it has also been a catalyst in the overall development of their lives. The programme works in an area previously closed to all
Christian groups and is the only NGO working in health and development in the area. The programme develops community groups such as farmers clubs, womens groups (Mahila Mandals) and youth groups, as well as training community health volunteers. Increasingly, individual communities take responsibility to collect and analyse information and make action plans. The groups become selfreliant in promoting nonmedical interventions which determine health such as organising water supply, improving agriculture, and dealing with unjust social structures and practices. Specific health programmes are organised for women and children as well as for control and rehabilitation for leprosy and tuberculosis. Great emphasis is placed on sharing information constantly and upgrading peoples knowledge base and skills. Villagers and grass-root workers are treated with respect and their good ideas are implemented in the programme.
During a time when the Aroles were not actively involved in the programme, groups of Jamkhed villagers went to stay in villages over 200km away. They organised Mahila Mandals and identified and trained VHWs. One of the Jamkhed villagers reported the tribal people are very poor. They are friendly and invited us to stay with them and share what they had. It was difficult for me because there was no water and there was filth and flies all around. Almost every family had scabies and skin infections. We had no choice; we had to stay in the overcrowded huts. Then I remembered that once we too had filth in our village and there was scabies. All of us determined to first get rid of the scabies just as we had done in Jamkhed. Water had to be fetched from a long distance. This did not deter us. We worked with the people and in three months got rid of the scabies. We encouraged the women to be involved in health activities; in spite of the physical hardships, it was a rewarding experience.
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Fig13 Graph showing decrease in malnutrition rate
Fig14 Graph showing increase in immunisation rate
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2
Focus on the poor - principle 2
Q Who are the poorest people in the communities you work in? Why are they poor?
For centuries Indian society has been divided into numerous different castes. The Brahmins or priests are considered to be the highest group. Others include business men and landowners. Outside the castes, and not even included as a category, are the untouchables and Dalits. They are forced to live outside the village and only given the dirtiest, most unpleasant work. Women, children and people with leprosy are also marginalised. Officially, the government has passed a law against treating some groups as untouchable but in practice the discrimination continues. This results in extreme poverty, oppression and apathy. In their eagerness to serve the poor, the Aroles learnt that they should not antagonise the leadership. In the initial stages, they took the existing leaders into their confidence and gradually worked with the other villagers until true leadership emerged among them. Since women had no place in village society outside the home, work initially began with the men. Farmers involved in health surveys saw the suffering of the poorest and began to plan actions to meet the most pressing needs. It became evident that health was not the priority of the poor at all. The majority were concerned with their very survival: work and food. To break down the barriers of marginalisation and caste, several interventions were initiated. Children of all castes cook and eat together and Dalits are encouraged to serve the food. Womens self esteem was built up through the Mahila Mandal groups. As the poorest people are empowered, efforts at reconciliation and co-operation among different groups are emphasised. Since health is dependent on the village community as a whole, it involves interconnected aspects of life. Often the individual can affect these only when there is co-operation among the members of the community for the benefit of all. There is much evidence of empowerment in Jamkhed; in many villages there is no longer any fear of social exclusion. Overcoming the caste system has not been an end in itself but a means to an end. The purpose is for transformation to self-reliance for the village as a whole.
Fig15 A) Diagrammatic map showing how dalits are not included in Ghodegaon Village
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Fig15 B) Diagrammatic map showing how dalits are now included in Ghodegaon Village Arole M & R, 1994, Jamkhed A comprehensive rural health project, Macmillan/TALC page 12 & 13.
1. 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.
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2
Sharing of skills to support the development of communities - principle 4
Q How could different people in a community get actively involved in health care?
Jamkhed has discovered that rural communities are capable of planning and maintaining their own health, provided they are taken seriously and not treated as ignorant people. The staff entrust health services to the people and the attitude of superiority is replaced by a feeling of equality and working towards a common goal. Staff have learnt to have faith that poor illiterate woman can gain the skills they themselves have. A staff member has said all that I know the villagers can know; it is my responsibility to decide how to transfer my knowledge and values to them. Everyone in the community has the opportunity for skill development, so that change does not rest with a few Village Health Workers or TBAs. This also avoids the risk of them becoming self-important experts. They receive their training in the community so that everyone can know what they know. For example, even the old men in the community can accurately describe how a baby should be delivered. Skill-sharing is combined with development of values. Village people have experience of coping with difficult
Fig16 Village health worker with village women Arole M & R 1994 Jamkhed A comprehensive rural health project, Macmillan/TALC page 197
conditions and have many useful home remedies. These are promoted together with appropriate modern technologies such as simple infant delivery packs and oral rehydration. The mystery of medicine is removed. In the case of harmful traditional practices, scientific information is provided and health workers are allowed to discover for themselves the effectiveness of scientific interventions. Information-sharing builds on positive traditional practices, never directly discrediting any
practice. Skill-sharing has evolved as part of an ongoing process. The message does not stay the same but new information is shared according to current community concerns and hence knowledge is built up over the years. For example, more recently in some villages, the community has arranged for most adults to have their blood group identified, so that if a woman has difficulty in labour, several people with the same blood group go with her to hospital.
Discussion question
1. What do you think are the Strengths, Weaknesses, Opportunities and Threats (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
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2
Resource mobilisation - principle 5
Q Where do the resources come from to run your programme ?
From the beginning, the Aroles used a programme planning, budgeting and review system with the objective of developing a sustainable health programme. The cost of care is discussed with the people using the data from morbidity surveys. It was agreed that recurrent operating costs would be kept low so that the village people could afford to pay for the services. Costs are constantly reviewed in relation to the objectives, such as reducing infant and maternal mortality, rather than in relation to maintenance of institutions such as a hospital. If a programme is not cost-effective, it is discussed with the people and either modified or discontinued. Therefore, when it was found that health centres in two of the areas were not contributing significantly to the health objectives, they were discontinued. Instead, primary care through village health workers was strengthened and a neighbouring health centre was upgraded to a small hospital. As far as possible, resources are generated locally while external funding is sought for capital expenditure and for seed money to initiate crucial programmes. Money from international donors was used to establish the curative services. Four years later, the medical aspects of the programme were being met with funds generated from the community, the government and a few local donors. From 1975, little external funding has been used except for special programmes such as leprosy and tuberculosis control. Initially new programmes such as immunisation and family planning have to be promoted. Now local awareness has grown to the extent that if these services are not available through government sources, the community pays for them. More recently, many villages decided on mass tetanus immunisation for the adult population. They collected the money and held the campaigns. Likewise Village Health Workers charge for their services rather than receive a salary. Contribution by the villagers is in spite of their poverty. As social and cultural barriers have been broken down, unity and care have grown so that villagers have found ways for even the poorest to receive the health care they need. The mobilisation of local resources has resulted in a high level of programme sustainability. (See also Principle 10, Secondary Referral, page 32 ) As the project evolved into a more holistic multi-disciplinary approach, many non-medical interventions were introduced. For instance, provision of safe drinking water to the villages required a large initial investment: 100 wells cost $70,000. However, the benefits of a clean water supply reduced morbidity and mortality by over 50%. The expansion of the programme has encouraged the villagers to work towards selfreliance. They are able now to mobilise resources from within the community and from government agencies and bank loans.
Fig17 Villagers working together to conserve water Jaeger M C, 1997, Tearfund
1. Why is resource mobilisation important for achieving programme sustainability? 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.
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2
Skilled, committed and motivated facilitators - principle 6
Q What qualites would a health worker need to become a good facilitator?
Initially, the Jamkhed staff had no skills, experience or qualifications. In fact it can be difficult in India to recruit Christian workers with the necessary skills, especially at higher levels. All staff receive continuous on-the-job training, including in the values and goals of the programme. Selfconfidence is promoted at all levels. Staff recognise that the process of enabling and empowering others and sharing knowledge and skills can only occur if they themselves have developed self-esteem. They all work in partnership. But first the hierarchy had to be broken in their own team. This meant that the Aroles refused from day one of the programme to be treated differently from the rest of the team. All meals were taken with everyone from the doctors to the driver sitting together in a circle. Hierarchical attitudes have been replaced by a team spirit and equality. The team has also realised that knowledge not only gives power, but that sharing knowledge also increases self-esteem and is important in the development of team spirit. While individual talents are developed and existing skills improved, it is necessary for legal reasons to have some staff with professional qualifications. For example, a qualified Assistant Nurse Midwife may be needed for some mobile team work. The villagers themselves say It is not important to have professional staff. Their attitude towards us is more important. They should not be arrogant, but be willing to identify what people know already. They need to be able to convince people that what they are doing is not for themselves, but because they believe in it; their lives should be transparent and without suspicion in order to win the trust of the people; it comes through love and forgiveness. The following story demonstrates how the potential of an uneducated staff member was recognised and developed. Moses Guram joined the team as a construction worker helping to build the health centre. He spent his time watching the motor mechanics, X-ray technician and electricians and because of his aptitude and interest, acquired many new skills. Eventually, he learnt how to make appropriate artificial limbs for people who have had an amputation, and he is now in charge of a workshop that manufactures equipment for physically handicapped people. He says I was trusted and knowledge was freely available in Jamkhed. Others shared their knowledge and skills with me. I was nobody. Today I am called doctor and many doctors and professionals take my advice. I share all the knowledge I have with the young men who work with me. Money cannot buy the joy that I have in my work.
Fig18 Moses fitting a limb Arole M & R, 1994, Jamkhed A comprehensive rural health project, Macmillan/TALC page 103
1. List the skills needed to be a community health development worker. 2. What do you think might be some of the difficulties that highly qualified professionals have with involvement in CHD? Do you have these difficulties 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 approach like Jamkheds to your programme, and b) draw a table to explain it.
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2
Efficient monitoring mechanisms and evaluation framework - principle 9
Q Who is monitoring & evaluating for, and why?
design questionnaires so that only necessary information is collected. The staff team provide technical input wherever needed. The survey helps villagers to assess their health status periodically. This provides the basis for discussion at meetings and inspires them to look for solutions, for example to problems of widespread malnutrition or high incidence of malaria. It also helps them to identify the impact of health education so that the village health worker can target her activities. It is a learning process for everyone involved. The information is not a set of figures to be sent to a distant official but a tool for improving the services in the village. The programme staff systematically collect and collate the information from the different villages for preparation of programme reports, but control of information in individual villages remains with the villagers. For many years each village has kept its own statistics board. As different issues become important, different indicators have evolved. They are specific to each village because each has its own problems. The villagers say It is not so much the statistics were interested in but how things are changing; for example getting rid of bad habits and what we are eating. We meet every day to discuss the days events. It is no big thing. Everyone knows about health; if theres a birth or death, we discuss it immediately. If a child dies, the whole village wants to know why. The frequency of recording depends on the actual data, so, for example, new TB cases are recorded weekly whilst family planning data is updated every three months.
Fig19 Villager in Ghodegaon explaining their statistics on the board Jaeger M C, 1997, Tearfund
From the start, Jamkhed staff believed that if people are to be involved in the decision-making, planning and implementation of programmes, they need to assess whether their programmes are working towards the objectives they have set. Gathering health information from house to house has become an annual feature. Members of the various groups in the village
Section three page 45 describes an evaluation carried out by villagers of the non-medical aspects of the programme.
1. 2. List some of the advantages and disadvantages of keeping statistics. 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.
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2
Secondary health care services for referral or networking purposes - principle 10
Q Why are secondary health services important?
A simple forty-bed hospital with diagnostic and surgical facilities supports the primary health programme. It is run by the programme staff on the Jamkhed ethos. Special efforts have been made to keep the cost of secondary care within the reach of the village people. By using overlapping job responsibilities, the cost of hospital personnel is kept at a minimum. When specialist services are needed, they are carried out through mass campaigns, for example, in eye camps. The hotel costs of care for patients are also minimal; relatives cook, clean and help in the nursing care which is in keeping with the local culture. The building is a low cost design and costs are further cut by only using appropriate technology. However, at no point is scientific sterile technique sacrificed. The cost of medicine is reduced by using medicines from the WHO essential drug list bought in bulk from reputable companies selling generic drugs. The hospital uses an effective cost recovery scheme. The programme found that if everyone, including the poorest, knows what the services cost, they will be more ready to pay if they can afford it. Totally free care is often not respected and valued. Discussions with the farmers clubs and Mahila Mandals have enabled the hospital to set fees that are within the ability of the poorer sectors to pay. Approximately 50% of the community can pay a little more than the cost of treatment, to offset costs for those whose treatment is subsidised. About 10% of patients cannot pay. The groups identify such people and work out ways of meeting the costs. The community may meet the cost through contributions or an arrangement may be made to contribute labour in some form. The programme staff aim for a balance between curative, promotive and preventive health services. They have seen that poor communities have a large backlog of disease. People need curative services for their immediate medical problems. These services can act as an opening for preventive programmes. Primary health care needs the support of secondary services. The village health worker must have the confidence that she can approach a secondary care centre for help when needed. Antenatal care without a back-up service for Ceasarean section will soon lose all credibility. Therefore, it is acknowledged that secondary facilities will always be needed.
Fig20 The Two Mules-Everyone benefits when hospitals and primary health
programmes work together TALC
Discussion question
1. What might be some of the problems associated with hospitals in relation
to CHD programmes?
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CONCLUSION
The case studies have described how three programmes demonstrate the principles necessary for effective community health development. They have much in common. All three have a clear vision to improve the quality of life especially for the poorest. Two of the three (ASHA and Jamkhed) were started by medical doctors with small curative programmes as the entry point. However, all three have realised that to fulfil their vision, health must be seen in its broadest sense and programmes need to be integrated and include non-medical interventions. But more than this, they recognise the importance of facilitating true community ownership of the programme. This means that individual villagers (or slum-dwellers) learn to work together in community organisations to take responsibility for changes in their lives. Skills and knowledge are freely shared between staff and community and within the community. Staff and community work together to break down social barriers and build relationships based on mutual respect and trust. The studies illustrate the importance of skilled leadership in living the values of community health development, understanding the communities, inspiring and training the staff and generating commitment from the authorities. This means relationship-building at all levels. Leaders and staff are seen to work as facilitators with the community. Partnership is also built with both government and nongovernment 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 based on Christian values. This means that every man, woman and child is treated with respect and given dignity and everyone grows towards their full potential.
Concluding questions/activities
1. 2. Review each of the 13 principles. What are the strengths, weaknesses, opportunities and threats of including these principles into your programme? Make an action plan for implementation of changes you would like to see in your programme in relation to the 13 principles. Please see Action plans in section three, page 46. 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 you about how best to work in the community. Also, although this case study and the guidelines relate to community health many of the principles apply whatever the specialism. It may be interesting to find out what a local agricultural organisations experience is of, for instance, focus on the poor, community ownership and skills sharing.
3.
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 may find that there are resources available to you to support your work. This visit may develop into a good working relationship with governmental officials that will assist you in the future.
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Section Three
Section Three
Comments on discussion questions Studying in small groups
Action plans Guidelines for good practice in community health development Glossary Abbreviations Recommended reading and references
COMMENTS ON DISCUSSION QUESTIONS

We, the author and editor, are aware that we cannot provide individual feedback to the questions we have 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 not answered 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 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 the start of a programme may need to change? 3. Does your project have clear vision, objectives and activities? Are they clearly linked and regularly reviewed? If YES , how have they changed as the programme has developed? How much is the community involved in deciding on the objectives and activities? If NO, what plan could you make to decide on setting your programmes goal, objectives and activities 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. For example, 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 a small demonstration programme; it will vary from one situation to another. It cannot be assumed from the start that the community knows everything: if they knew everything, they would not be where they are. Concentration on objectives can change the focus from the community on to the project. The goal of bringing health to the poorest remains, but specific objectives and activities need to change according to changes in priorities. For example, after three years, ABCD undertook a major review of its objectives and adapted the whole framework to be more gender sensitive. This was in response to awareness-raising of gender issues. Political instability, difficulties in recruiting staff and security incidents have all caused delays and changes in ABCDs original plans. Other reasons for changing objectives and activities could be in response to changing health patterns, as the programme makes progress in addressing priorities identified in the initial assessment.
2.
You may find it helpful to refer to the Planning, Monitoring and Reporting Manual (Brown S,1997)
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3
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 for the next 3 years. The format for reporting should be simple to reduce the time spent on it and should be userfriendly 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 not dictate 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 poorer the village, the harder it is. There are benefits in spreading the funding between several donors though this may mean considerable time having to be given to administration and report writing in order to follow the 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 with each other.
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ASHA
Ownership by the community - principle 3
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 be overcome?
1.
The question continually arises: What is community in a slum? Urban slum communities are often made up of a mobile group of people who do not tend to stay long but move on in search of a livelihood. Such communities are also heterogeneous; people come from different states and cultures. These factors make unity and working together hard. In addition, some slum populations tend to be large (30-40,000 people). The size of the slum affects the ownership of the project and more often ownership is limited to a small section. Much time needs to be given to relationship 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 it impossible to work in that slum. Yet in spite of the difficulties and because of their love, skill and persistence, ASHA has seen large numbers of slum-dwellers able to form groups and help themselves towards significantly improved health and general well-being. In the relatively homogeneous and stable setting of rural villages, the community is also a collection of different groups. For example, groups may be identified by ethnicity, religion and class or caste. These groups may represent conflicts of interest even in very small villages. The challenge for programme staff is to find ways to support co-operation between the groups, compromise where necessary and the breaking down of barriers between people.
2.
Difficulties ASHA has experienced in gaining community ownership and participation in the slums include: slums lack soul; the community has no roots or culture; people are only there for the money; people do not even know their neighbours insecurity: any day peoples homes may be demolished the resistance of some slum dwellers who feel threatened or fear losing power the lack of awareness, education and confidence amongst slum dwellers resulting in an inability to believe they can change things the expectation of a few slum leaders and dwellers that organisations such as ASHA should provide, rather than that they should be involved in self-help and community involvement government red tape which prevents or slows effective utilisation of resources internal slum politics and rivalries continuing poverty and economic marginalisation of slum dwellers lack of political will by politicians to improve the lot of slum dwellers significantly mobility - the population is constantly coming and going community groups need somewhere to meet but space in slums is rare: there may not be enough space for even a meeting of 50 people.
3.
To overcome difficulties in gaining community ownership requires perseverance together with a firm belief in the peoples ability to take control of their lives and therefore in the value of ownership.
37
3
Skilled leadership - principle 7
1. Dr Martin did not start the programme with a proven track record of implementing successful community health development programmes? What do you think are the aspects of her leadership which have made the programme successful? 2. What qualities of leadership are necessary in your programme?
1.
This project and others have demonstrated that if leaders are sensitive and caring, they can learn facilitation skills as they learn together with the community. ASHAs staff believe that a leaders values are more important than high professional qualifications. Villagers in another programme have also said that motivation is more important than professionally skilled leadership. Dr Martins vision for the realisation of lasting change in peoples lives has been key in the programmes success. So also are her love and ability to relate to people at all levels of society, her skills in enabling and providing direction, her determination and finally her commitment - all motivated by her love for Christ. 2. Management theory has identified several management styles which range from autocratic and directive to consultative. The skill of good leadership depends on the leader knowing their preferred style but having the ability to be flexible depending on the situation and need.
Appropriate activities - principle 8

1. Which of ASHAs activities would you consider to go beyond normal community health activities, and why? 2. Why do other programmes not normally carry out these activities? 3. What aspects of these activities do you think have been important to the success of ASHAs programme and why? 1. Activities found in ASHA which go beyond conventional approaches to community health include the emphasis on community organisation (Mahila Mandals) and the empowerment and advocacy work. The environment improvement programmes (clean water, sanitation, street cleaning etc.) would also be outside the norm in some narrow definitions of community health. But ASHA is about more than just improving physical life. It is a hope of the staff that the slum dwellers, the poorest of the poor, would grow in their sense of dignity and make changes for themselves. Sometimes interventions may not be fully effective but are needed for maintaining public relations or as an entry point; for example curative services can be an entry point for primary health care. 2. There are many reasons why this broad range of activities are not included in many other community health programmes. These could be: vision for empowerment in communities and the need to develop human potential is not understood expertise and training of staff is often limited to in-service provision (bringing clinics/health education to the community etc.) and not facilitation skills donor/government/staff pressure to achieve quick results government pressure exerting top-down control unwillingness to learn other ways etc, etc. 3. As stated in question 1, these activities encourage dignity, self worth and confidence enabling even the poorest to take part and own the programme.
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3
Partnership with local and national government - principle 11
1. What difficulties do you experience in working with government organisations? 2. Make a plan to show how you could begin to improve this situation bearing in mind ASHAs experiences? 1. It is not always possible to gain government support and approval because the authorities may not be interested in the poor. It depends on the values of the group you are working with. In general, programmes should work with and use government resources because this is the communitys right. Therefore, they can demand government services, not just participate in them. However, the organisation should beware of becoming contractors of the government. We should not do the work for them but complement it; for example, in immunisation work. Ultimately the major input of programmes like ASHAs should lie in the values they seek to extol. If government money is taken, it is necessary to follow government direction, which may not agree with programme principles. For example, many government led health programmes segregate leprosy and TB treatment into separate programmes; this is against the principle of integrated primary health care. Each situation must be separately assessed. A lot depends on the local government person involved. 2. Some points to consider in your plan. Commitment to building relationships with local government staff is very important. Staff and villagers need to gain self-esteem to be able to approach government authorities both with confidence and with humility. This takes time, effort and commitment.
Partnership with national/international non-government and community organisations - principle 12

1. 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 ways you 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 common with organisations involved in agriculture and income generation for instance. 1. Partnerships are improved by mutual respect, clear shared vision and commitment to relationshipbuilding. Negotiation, compromise and perseverance may be necessary. Shared resources and mutual support can bring greater benefits to both organisations than if they worked separately. Difficulties can arise through the effects of an unequal power balance in the relationship, and the different organisations having different agendas.
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JAMKHED
Focus on the poor - principle 2
1. 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.
1.
Where community health programmes are chiefly provision of services, there is a big risk that the poorest do not participate. In Jamkhed, the villagers themselves identify the poorest and select where the programme should focus. Jamkhed believes target groups must be identified by the community; that outsiders will not be able to identify the target group and that there is a danger in believing they can. Outsiders cannot fully understand the community, and therefore risk missing the poorest especially where they (the outsiders) depend on their own conventional understanding. Who the poorest are varies from one community to another. In Jamkhed, the identification of the poorest is done in mixed groups of people to ensure honesty. Furthermore, Jamkhed has seen that it is not enough only to identify the target group; for a programme to be effective, it must actively focus on the poorest.
Sharing of skills - principle 4

1. List the Strengths, Weaknesses, Opportunities and Threats (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. 1. Strengths: In Jamkhed the belief is that everyone can learn skills. Therefore, a key strength is the breakdown of hierarchies based on superior expertise. Opportunities: The more people gain skills, the more can be done. Weaknesses: Skill-sharing takes time and requires good management. Threats: Some professionals may find skill-sharing threatening with non-professionals, and those in authority may fear loss of control, so that power struggles follow.
Resource mobilisation - principle 5

1. Why is resource mobilisation important for achieving programme sustainability? 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 increase its sustainability. 4. Draw a diagram to show the type of hiresources needed, and which can be obtained from within the community and which from outside.
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1. Sustainability for Jamkhed means empowering communities to choose their own objectives and find their own solutions. It does not mean survival of the institution that enabled the programme. As the development process has continued, many programmes in Jamkhed have become redundant. New priorities have emerged needing new programmes. Therefore, sustainability does not mean finding alternative funding for the same programme for many years. Nor does it mean handing the programme over to the government. Experience has shown that it can take a very long time, many years instead of many months for improvements to occur in the lives of the poorest of the poor. The poorest 10% of a population can be the hardest to reach and may need a great deal more resources than the other 90%. Since 1989, the programme has been gradually withdrawing as many of the community organisations have become self-reliant. Many Mahila Mandals now mobilise their own resources. For example, some have started income generation activities and pre-school nurseries. They organise health camps and continue to monitor the health of their children. They work closely with the government nurse-midwife and ensure that primary health care activities are maintained. The Jamkhed experience shows that investment in the building of self-reliant communities is crucial to sustain improvements in health and needs to be stressed in the development of primary health care. External contributions should be simple and effective; they should be run by the people rather than local level workers. Financial planning will change as the project develops. 2. It is unnecessary to have the full range of necessary expertise (for example, water engineers, animal health experts etc.) in the project team. Networking with other local agencies can give access to valuable resources. It is important that outside experts recruited to assist in community health development follow the ethos of the programme and not their own agenda. There should be caution in assuming the community will want to use these experts.
Skilled committed and motivated facilitators - principle 6

1. List the skills needed to be a community health development worker. 2. What do you think might be some of the difficulties that highly qualified professionals have with involvement in CHD? Do you have these difficulties 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 approach like Jamkheds to your programme, and b) draw a table to explain it. 1. Project staff should be highly skilled in facilitating community organisation and understand basic health. Other skills can be obtained elsewhere. Jamkhed has found it is not necessary for the staff to have all the technical skills needed for community development. They can obtain outside help from experts, for example government water engineers, at no cost. Jamkhed staff receive value-based training. This means developing genuine love, sacrifice and perseverance. First they learnt that they were human beings with dignity, recognising others as human beings and the concept of equality. They learnt to value themselves and to be careful not to divide or partition the people, but bring them together. They believe that every human being is made in the image of God. This Christian value motivates professionals to love and respect all
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3
people and recognise the tremendous potential in each of them. As they love and care for the people, the village people in turn make their community a caring community. Jamkhed staff realise that to be trainers, they must be willing to share all their knowledge. They must be willing to satisfy the desire of trainees - what do they want to know? Skills identified by staff as important include communication skills, facilitation skills, trust in the students ability always to encourage people, tolerate mistakes and stand with them in difficulty, delegate and help till independence is achieved. They know that it is not essential to have a special education or degree - honesty, motivation and love are much more important. 2. Difficulties highly trained professionals may have with involvement in CHD include: the temptation to want quick results attitudes of superiority to those less qualified (and pressure from others to adopt a higher position) requiring larger salaries than the programme is able to pay (or if high salaries are paid, less resources are available for other programme costs) inability to identify with and believe in the poor and vulnerable unwillingness to live in remote underdeveloped areas loss of the status they could achieve by practising their profession elsewhere difficulties in changing unhelpful attitudes. 3. All too often, staff feel isolated and unsupported in community health programmes. This can lead to loss of motivation and poor practice and therefore to the community losing confidence in them. Jamkhed uses a team approach for staff to support each other. They see this as more important than supervision which to them indicates hierarchy. Each person knows their own responsibilities and knows what the others are doing. Each morning all staff meet to share so everyone knows what is happening in the programme and can support each other. Volunteer health workers come together regularly from their villages for mutual support and upgrading of their skills. They are also visited regularly in their villages by programme staff.
Monitoring and evaluation - principle 9

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? If so, write down the steps you would take to do this. 1. Advantages of keeping statistics include: they provide a tool for programme monitoring so that action can be taken quickly or programmes adapted as necessary they may be required by government authorities and donors. Disadvantages include: time spent monitoring can take away from time spent working with villagers statistics can be very complicated - simplicity and relevance to the community are very important often data collected is not acted upon monitoring requires some administration capacity which can divert resources away from other more directly relevant work.
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3
Statistics must be relevant to the community. External evaluations are expensive and need to be carefully chosen and undertaken bearing in mind the nature of the project. There should always be close discussion with project workers and with the community.
3. It may be helpful to refer to the Planning Monitoring and Reporting manual (Brown S,1997)
Secondary referral - principle 10

1. What might be some of the problems associated with hospitals in relation to CHD programmes? 1. Problems associated with hospitals in relation to CHD could be: government hospitals are often too underfunded and too bureaucratic to be sufficient to meet the needs and therefore CHD is not adequately supported by secondary care the cost of hospital care may be prohibitive for poorer patients secondary referral facilities which are not managed by the programme may not be based on the same ethos: for example, intravenous fluids being used by referral centres to treat diarrhoea rather than oral rehydration salts where hospitals are linked to CHD programmes, hospital staff may consider themselves superior to those in the community and undermine the work of empowerment by CHD staff. This is particularly a problem when hospital staff have not understood the value of integrated community health care.
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Studying in small groups

Any number greater than one allows you to discuss, share and learn more easily and often with more fun! Between 6 - 8 people is normally recommended for a group to work efficiently, but we suggest that any number from 2 to a maximum of 8 will be satisfactory. You might want to experiment: for instance, instead of one group of 6 or 8 try 2 smaller groups of 3 or 4 but join together at the end of your time for 15 minutes or so, so that each of the small groups can share what they have learnt with the other group.
Organisation
Chairperson
We suggest that someone in the group is selected to be the chairperson. They do not have to be the most senior person present and you could just take turns. The reason for appointing a chairperson is to keep you to time and to encourage everyone to speak and contribute.
Scribe
Each time you meet it would be good to keep a record of what you have learnt together. You may also like to make a note of the aspects of your work that you would like to change in the light of what you have learnt. We suggest you either select someone to be the scribe or take it in turns. Your notes will be useful if you decide to make an action plan to change your current working practices. (Please see page 46 - Action Plans)
Aim & task

The case studies are quite long and you may decide it would be better to work on the material over a few sessions. If this is the case, you will need to decide how long to meet for and how much of the pack you want to do in a session. For instance, you may want to have all read the whole pack before you meet and then use: session one - to discuss and note down your initial thoughts; session two - to look in detail at one of the case studies and answer the relevant discussion questions; Following sessions could be divided between the rest of the case studies with a final session to summarise what you have learnt and to write an action plan.
Learning objectives
We stated what we expect you to learn from each case study. These objectives will also help you to decide what and how much you want to do in a session.
Equipment
You will need: Enough copies of the case study so that everyone can have the opportunity to read it before you start the group work. (Although this is copyright material we are happy for you to photocopy it for this purpose) Note paper and pens for participants to take notes. Note book to record your summarised learning and action points for each session.
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RE FL EC TIO N AN D LEAR NI N G FO R GOOD DEV EL OPM ENT PR AC TIC E

(See principle 9 , Monitoring and Evaluation, page 31) In 1983, representatives of the farmers clubs, Mahila Mandals, village health workers and social workers joined in planning an evaluation of the non-medical aspects of the programme. They used mainly house to house surveys and focus group discussions. 57 villages were surveyed and sub-divided for comparison into three groups according to the length of time they had had functioning farmers clubs and Mahila Mandals: A above 5 years B 2-5 years C 1-2 years The evaluation group set their own criteria for economic classification: 1. Well off Those assured of food twelve months of the year 2. Average or poor Those assured of food nine months of the year 3. Very poor Those assured of food less than nine months of the year Changes in attitude and practice towards caste and status of women were judged by observation, impressions and discussions in focus groups conducted by the farmers and womens groups. Criteria for caste problems: 1. Are Dalits allowed to draw water from the common well? 2. Do people of different castes help each other? 3. Do all children of all castes participate in the nutrition programmes? 4. Do people of all castes eat together at weddings? Criteria for womens status: 1. Are women allowed to speak to leaders? 2. Are women allowed to come to public places? 3. Do women participate in village affairs? 4. Do women participate in literacy classes? 5. Do women participate in decision-making in the family?
Following this exercise several changes in strategy were suggested. These arose mainly from the focus group discussion. The staff learnt that it takes a long time for change to happen; that it takes three years or more for people to organise. More than five years are needed for lasting changes to take place.
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ACTION PLANS
The following questions may help you to develop your plan:
1. What have you learnt? List the main points. You may already have these noted down. 2. What would you like to see your programme achieving in the future? (Vision) 3. In the light of the case studies do you now believe your objectives need to change? If so, in what ways? (Objectives) 4. What can you start to change immediately? 5. What can you begin to change over a period of time? 6. How are you going to do this? (Activities) By reflecting on these questions you will further develop your vision & goal, objectives and activities. Further reading: Manual for a workshop on planning, monitoring and reporting, by Dr Steve Brown, 1997, Tearfund .
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Guidelines for good practice in Community Health Development

1 Clear vision, objectives and activities
There needs to be a clear link between goal, objectives and activities Objectives are SMART: specific, measurable, achievable, relevant, time bound Recognition that the process of undertaking the activities is important Communities become progressively more involved in setting and owning goal and objectives Objectives are flexible over time as changes occur in the community and in external circumstances
2 Focus on the poor

The poor: Are economically poor and powerless including women and children and the low caste, marginalised, disadvantaged, oppressed, isolated, people with disabilities and ethnic minorities Include communities experiencing inequalities in health e.g. high infant mortality, high maternal morbidity/mortality
3 Ownership by the community

In order to achieve active participation and ownership by the community the facilitator allows significant amount of time for relationship building and community organisation Community become increasingly involved through : - early commitment from the community to work in partnership - needs assessment by the community of the community's perceived need - creation, identification and implementation of solutions - resource mobilisation - monitoring and evaluation - leadership Communities have an increasing capacity to initiate, change and make choices in an environment of supportive relationships
4 Skills shared to support the development of communities

Skill sharing that builds on the skills and knowledge of the community Wide range of people from within the community have opportunities to develop skills in: - needs assessment - identification and analysis of problems and the underlying causes of problems - creation, identification and implementation of solutions - resource mobilisation - monitoring and evaluation - group empowerment - communication - leadership Skill sharing that adjusts as the community develops
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5 Resource mobilisation
Use contributions external to the community to give momentum to self sustaining development Identify clearly who is contributing what to the activities e.g. government may provide vaccines and some staff, community may provide buildings and finances, donor agency may provide finances Identify a realistic cost recovery plan wherever possible Identify local resources and how external input will decrease and local input will increase e.g. from the community, local government, other local NGOs Identify full and comprehensive costs for specific services Provide quality support to all levels from the community to top management
6 Skilled, committed and motivated facilitators

Facilitators/promoters/enablers work in partnership with communities to build healthy, self reliant communities Facilitators are committed, motivated and have a love for the poor and are willing to give and receive feedback Facilitators understand the socio-cultural reality of the community Skills and experience required by staff to achieve programme goal and objectives have been identified Skills include: facilitation, communication, leadership, group process, training, needs assessment, programme design, programme implementation, relevant technical skills, monitoring, evaluation, resource management and budgeting Staff training and personal development plans are linked to the skills required to achieve programme goals and objectives
7 Skilled leadership
Has a proven track record of implementing successful community health development programmes Has ability to inspire and motivate project staff and communities with a vision for what can be achieved and has the ability to devolve responsibility and mentor potential community health development leaders Has the ability to plan and work at a strategic level Is an example of a lifestyle that reflects positive values e.g. humility, flexibility, ability to adapt to the culture and language of the community, patience, reliability and accountability Is flexible, able to adapt to the changing needs of the project and willing to give and receive feedback Is able to support staff and communities in finding creative solutions to problems
8 Appropiate activities
Community organisation is the focus Appropriate identification of target group by the community, activities planned by and acceptable to local people, run by people from the community Activities start small and develop slowly Activities are effective and sustainable in relation to both cost and outcome, activities work within locally available resources as much as possible Innovative ways of working are encouraged Activities for which there is no research information on effectiveness are first 'piloted' and appropriate monitoring and evaluation mechanisms put in place Project staff keep updated on what is proven to be effective Avoid copying commonly promoted activities which may not be relevant or effective in developing self reliant, empowered communities
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9 Efficient monitoring mechanisms and evaluation framework

Simple and not time consuming mechanisms and framework but which provide relevant information so that effectiveness and progress towards sustainability can be measured Ongoing internal evaluation and reflection is taken into account from the very beginning and is progressively set and implemented by the community Are linked to programme goal, objectives and activities Are adapted as necessary as the project develops Often includes an evaluation at two to three year intervals by individuals or teams outside the organisation
10 Secondary health care services for referral or networking purposes

Active co-operation between the different levels of health care If the community health development programme is part of an integrated health project, secondary health care services: - are actively health promoting - support and promote the work of the community health development programme An acknowledgement that secondary health services (e.g. hospitals) will always be necessary
11 Works in partnership with local/national government

The goal, objectives and activities of the community health development programme: - are contributing to local and national government health strategy - have the support and respect of local and national government if possible - work with and use government resources - indicate how they could be integrated into existing health infrastructure if not already part of it
12 Works in partnership with national/international non government and community organisations

Actively co-operates with organisations who represent other sectors that influence health e.g. agriculture, water supply, education Clearly defines and shares objectives for working together, where possible, with organisations present in the area. This may involve requesting an outside organisation to come in to provide certain expertise (see point above) Recognises and builds on the strengths of each organisation Avoids duplication of activities, instead maximises inputs and resources
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13 Works in partnership with donor agencies

Achieving effective and sustainable community health development programmes takes time! They start slowly and are small. Donor agencies and health professionals who want specific visible results within short timescales tend to damage the long-term effectiveness and sustainability of a programme In effective and sustainable community health development programmes donor agencies often commit themselves to supporting the project for a minimum of five years The reduction or removal of funding is part of a shared long-term plan Flexibility is provided to allow for unforeseen circumstances and also changes and developments within the programme to meet the varying needs of communities Project proposal formats and reporting mechanisms are as simple as possible Donor agencies understand the challenges faced implementing effective, sustainable community health development programmes and give support and encouragement.
(Muriel Chowdhury, October 1997)
Fig13 Graph showing decrease in malnutrition rate
Fig14 Graph showing increase in immunisation rate
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GLOSSARY
Animators
Staff who are skilled in encouraging people to analyse their situation and find their own solutions
Awareness-raising
Increasing the communitys consciousness of issues which are important and relevant to them
Community health workers, village health workers, village health volunteers

People belonging to and chosen by the community in which they work, who implement affordable, appropriate, relevant health programmes
Community organisation
Groups that represent various sections of the community are formed to work on behalf of the community
Development
A process of change during which people are able to reach their unique God-given spiritual, physical, mental, emotional and social potential
Empowerment
The process by which people gain self-confidence and self-esteem towards realisation of their potential
Felt need
A need which the community themselves have identified and expressed as being important to them
Mahila Mandals
Womens groups
Ownership
The community has the control at all stages in the programme process
Participation
A process of inclusion of individuals or groups in decision-making and action
Participatory rapid appraisal

A tool for gathering information with the community
Praxis
An ongoing process of action, reflection, learning and then more action
Sustainability
The continuation of the changes the community is seeking to make through its programmes
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ABBREVIATIONS
ABCD ASHA CHD CHW/CHV MCH NGO PHC TB TBA VDC
Agriculture, Business and Community Development programme Action for Securing Health for All programme Community Health Development Community Health Worker/Community Health Volunteer Mother and Child Health Non-government Organisation Primary Health Care Tuberculosis Traditional Birth Attendant Village Development Committee
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RECOMMENDED READING
*Arole, R. & M. (1994) Jamkhed, a comprehensive rural health project. Macmillan, Basingstoke, London.
Batchelor S, (1997) Transforming the mind by wearing hats! Agriculture, Business and Community Development (ABCD) Case Study, Tearfund. Batchelor S, (1996) Transforming the slum by relationships, ASHA, Tearfund
Brown, S. (1997) Manual for a Workshop on Planning, Monitoring and Reporting , Tearfund.
*Chambers, R. (1993) Rural development - putting the last first, Longman, Harlow.
Hope, A & Timmel, S. (1984) Training for Transformation, a handbook for community workers, Mambo Press, Zimbabwe. *Hubley, J. (1993) Communicating Health, Macmillan, Basingstoke, London.
*Jaeger M C, (1998) Notes on community participation, Un published paper Tearfund.
*Macdonald, J. (1993) Primary Health Care, Medicine in its place, Earthscan, London.
Other References
*ASHA (1997) annual report. *ABCD 96/97 Annual Report, Appendix Z.
* Only availible in English
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Community Health (1) - Community Health Study Pack

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Community Health (1) - Community Health Study Pack

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

Community Health Development

ASHA Overview of the programme

JAMKHED Overview of the programme

Fig1 What is community health development?

Community health development (CHD)

Who is this case study pack for?

How to use the pack

What is community health development?

Origins of community health programmes

Fig2 Time line

Health Education Access to secondary referral

Problems with the general approach to community health

Fig4 deprivation trap from Chambers R,

A development approach to community health

Fig5 Chowdhury M, 1997

Tearfund Community Health Development Guidelines

Finally, a few words of caution:

ASHA Overview of the programme

JAMKHED Overview of the programme

ABCD Overview of the programme

Fig7 Village in Prey Veng Jaeger M C, 1997, Tearfund

Fig8 Village development committee

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

ASHA Overview of the programme

Fig 9 Ekta Vihar slum colony

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

Community based Primary Health Care

Fig11 Community health volunteer with a

Environmental and Sanitary improvements

Empowerment and development of potential

success of the programme, and why?

bearing in mind ASHAs experiences.

JAMKHED overview of the programme

Fig13 Graph showing decrease in malnutrition rate

Fig14 Graph showing increase in immunisation rate

programme and with whom

Fig17 Villagers working together to conserve water Jaeger M C, 1997, Tearfund

be obtained within the community and which from outside.

COMMENTS ON DISCUSSION QUESTIONS

Appropriate activities - principle 8

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

Sharing of skills - principle 4

Resource mobilisation - principle 5

Skilled committed and motivated facilitators - principle 6

Monitoring and evaluation - principle 9

Secondary referral - principle 10

Studying in small groups

Aim & task

RE FL EC TIO N AN D LEAR NI N G FO R GOOD DEV EL OPM ENT PR AC TIC E

Evaluation of non-medical aspects of community health development

RE FL EC TIO N AN D LEAR NI N G FO R GOOD DEV EL OPM ENT PR AC TIC E

RE FL EC TIO N AN D LEAR NI N G FO R GOOD DEV EL OPM ENT PR AC TIC E

Guidelines for good practice in Community Health Development

2 Focus on the poor

3 Ownership by the community

4 Skills shared to support the development of communities

6 Skilled, committed and motivated facilitators

9 Efficient monitoring mechanisms and evaluation framework

10 Secondary health care services for referral or networking purposes

11 Works in partnership with local/national government

12 Works in partnership with national/international non government and community organisations

13 Works in partnership with donor agencies