some critical notes to community workers

Some Critical Notes to Community Workers

There have been many approaches by health and government sectors to develop healthy communities.  Private, federal, state and local agencies have invested lump sums of money into programs that were funded to improve the health and well-being of a community.  However, there has been a lack of valid and reliable data that measures the impact these programs have on the actual health and well-being of the community and it’s residents. Each approach has struggled with the ability to establish realistic goals and to find reliable tools that effectively measure and evaluate the impact of their efforts.

One significant problem for the majority of funded programs is the lack of ability to set clear, definable and measurable goals.  In addition, these programs fail to communicate the primary objective of their efforts and the potential outcome for the residents.   Furthermore, it may not be clear to the workers or participants exactly what their programs are supposed to accomplish.  For example, many residents never ask what is an HIV/AIDS support group supposed to produce?  Or what are the intended results of a day program for adults with severe disabilities?  The actual objective of these programs in many cases may only be to have a point of contact between a worker and a community resident (Martin, 1998).  To compound this problem, even when goals are defined and measurable, tracking and standardizing them also presents a challenge.  In a business that is, at its core, focused on meeting complex individual needs, standardized measures must consider variables such as personal motivation and capabilities, funding availability and constraints and other community resources, if they are to be meaningful.  There are a number of community programs, however, that have been committed to and successful with measuring their productivity by using total quality management principles.  While many have viewed such achievements as the cutting edge, it can be assumed that other organizations will soon join these ranks.  Lawrence Martin (1998) states, “While it is much too early to begin to speculate on what impact quality tools may ultimately have, its current popularity in the public and private sectors suggests that most community programs will have a close encounter with quality management principles sometime during the decade of the early 2000s”.  However, community programs continue to lag behind other fields in measuring their outcomes.  Very little literature exists on how to apply the basic quality principles to these types of settings.  In addition, only a small amount of studies have looked at what tool would enable communities to not only measure their progress but also to understand the impact (outcome) of their efforts, as well as why progress is or is not happening (Cuadros, 1997).

The second most significant problem with measuring a program’s outcomes is establishing a national standardized formula containing essential measures that equate to health and well-being. The health of people in most settings currently is only being measured by the cost of medical services and death rates lifetimes (Agency for Health Care Policy and Research, 1999).  It is very important to realize that the root meaning of the word health comes from ancient references to “whole” and “holy” (Webster, 1996).  A much wiser definition of health is wholeness —physical, psychological, economic, intellectual, social, ecological and spiritual well-being (America Nurses Association, 1998).  Each person has a unique pattern in which these elements of wholeness are integrated into their lives.  Thereby, a state of health/well-being encompasses not only the body but also the mind and spirit (Collins, 1995).  It is a multidimensional subset influenced by a host of lifestyles, infrastructures, physical, social and environmental factors (Zucconi & Carson, 1994).

The third most significant problem with measuring a program’s outcomes is letting the efforts take root, sustaining the gain while maintaining a quality commitment.  Popular literature contends that more than 70% of all quality initiatives fail, indicating that initiating and sustaining quality in programs are not problems for just nonprofits/community programs.  The additional challenge that community programs may experience is the lack of resources to sustain quality initiatives in the form of training, personnel, and recognition and reward practices.  With tight budgets, it is difficult to justify these types of expenditures to donors and funding sources (Cox, 1999).

 

frequently asked questions - part II

How do the tools assist in community-based initiatives implementation?

CBI tools assist in the following functions:

• planning

• organization

• human resource development

• community survey and prioritization

• project preparation and implementation

• supervision and monitoring

• financial management

• documentation and reporting

• promotion and advocacy

• programme evaluation.

What are the links between community-based initiatives and

national development agendas?

Potent strategies for achieving equitable development at the local level are made available by employing CBIs. These strategies involve utilizing a combination of measures which address all determinants of health; they also support underprivileged communities in attaining self-sufficiency and self-reliance to boost development. With the common objectives of social well-being and community development, different sectors work together to support local health and social conditions in line with national strategies and agendas.

 

What is a basic development needs programme?

A basic development needs programme uses an integrated socioeconomic approach which is aimed at enhancing quality of life and improving health outcomes. It promotes holistic development focusing on the principle that health should be pursued using all available means. In this approach, the basic needs of each community are addressed and prioritized in order to achieve sustainable development with health as the central goal.

The basic development needs approach intends to achieve the following objectives:

• mobilizing and organizing communities and capacity-building;

• implementing bottom-up and needs-based socioeconomic interventions;

• promoting partnerships and developing effective intersectoral coordination;

• integrating health services at community level in order to reduce the burden of disease and promote healthy lifestyles;

•encouraging self-reliance and self-management for sustainable development.

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What is a healthy city programme?

A healthy city programme is concerned with the physical, social, economic, and spiritual dimensions of urban development. The programme works on the principle that health and quality of life can be improved by modification of conditions in the home, the school, the workplace, the city and other places or "settings" where people live and work. It addresses issues such as upgrading health services, water supply, sanitation, pollution, and housing in the urban setting. It can also focus on promotion of healthy life styles, providing a helping hand for projects and activities that can generate income, improving education, addressing women’s issues and children’s needs, and

enlisting the support of volunteer groups.

 

What is a healthy village programme?

A healthy village programme is an approach to enhance and accelerate the process of achieving health for all. In this process, priority is given to creating a supportive environment with a focus on village development for improving the health and wellbeing of the people. Provision of a potable water supply, sanitation, solid waste removal and village cleanliness are major components of such an environment. For achieving these targets, organized participation of communities and strong intersectoral collaboration at all levels are considered essential. A healthy village programme offers health professionals and community leaders a unique opportunity to adapt health activities to local circumstances.

 

How do these three approaches differ from each other?

All CBI approaches have the common objective of achieving health for all through health and development interventions. Basic development needs and healthy village programmes are implemented primarily in rural areas following common objectives, structures and process. A healthy city programme works in the urban localities, especially in the underprivileged suburbs for improving environmental conditions and bringing health onto the agenda of local development.

 

What is meant by “women in health and development”?

This includes any endeavour which aims to facilitate the development of gendersensitive policies and programmes in order to improve the socioeconomic status of women. The Eastern Mediterranean Regional Office of WHO has integrated gender considerations in all facets of its work, supporting Member States to promote the proactive role of women in health and development issues. They are also encouraged to enhance of the role of women in CBI. The objective is to mainstream gender in CBIs and other WHO programmes as central to all efforts for achieving sustainable development.

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What are the structures of community-based initiatives?

The structures in basic development needs and healthy village initiatives are almost identical in composition. They include:

•a community development committee

•a cluster representative from each cluster of the locality

• technical committees and groups for health, environment, education, financial management, women and youth

• a programme manager and intersectoral technical support team at programme level

• a national focal person at country level

• intersectoral councils from national to district levels (desirable).

 

In a healthy cities programme, the implementation structures include:

• a steering committee at city level, comprising members of the various organizations involved in the programme and chaired by a leading authority of the local government

• programme office

• working groups for specific plans and actions related to different sectors

• a city health forum consisting of health related individuals and stakeholders.

Promoting women in health and development initiatives is implemented by organizing women’s committees and integrating women’s development activities in other CBIs.

 

What is a social contract?

The CBI approach works through the joint collaboration of the community, intersectoral technical teams, programme management and other stakeholders, including WHO. In order to formalize these partnerships, a social contract is agreed upon by all partners at the start of the programme implementation in each area. The social contract contains key targets to be achieved within a specified period and describes the roles of each partner for achieving the desired goal. The contract keeps the partners, especially the communities, accountable for the set of targets determined and provides a broader base for programme implementation.

 

What are development packages?

In order to better achieve the targets agreed in the social contract, development packages related to components of the health, social and economic sectors have been produced. These packages are intended as a guide for the communities and the technical support teams. Health should be the main focus, and actions should be carried out bearing this in mind, irrespective of the priorities defined by the communities. On the other hand, interventions related to the social and economic sectors should be needsbased and subject to practical and financial considerations.

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What is social development and how does it differ from economic

development?

Social development is related to human well-being and improvement of quality of life; it allows people to live in a way that gives them a sense of satisfaction. They have access to the basic facilities required for sustaining life and do not feel deprived of opportunities or rights. Economic development, on the other hand, affects only one aspect of quality of life: it increases assets and incomes of individuals and communities. It is also essential for developing infrastructure and purchasing amenities. It should not, however, be the ultimate objective; rather it should be used as a tool for ensuring access to social services and improved quality of life of the population.

 

Why is income generation undertaken?

Poverty as the root cause of social evils is a multidimensional issue affecting all aspects of life. Ill health and poverty are intrinsically linked, and mutually reinforcing. Ill health brings disastrous consequences for individuals and their families by shrinking household savings, reducing productivity and diminishing quality of life. It creates or perpetuates poverty. The poor, consequently, are exposed to greater personal and environmental risks. They are poorer nourished and have limited access to health care; therefore they are more at risk of illness and disability. At the same time, better health prevents poverty and generates wealth by building human and social capital and increasing productivity.

The CBI programmes promote economic development and poverty reduction by supporting micro-credits and financing schemes for the underprivileged and poorest segments of the community in order to empower them and enable them to value and protect their health and productivity.

 

What is seed money?

This is the initial monetary support extended by sponsoring agencies to initiate the development process and to enable communities to meet their basic needs. The seed money is utilized for loans for income generation schemes and grants for health and social activities. The seed money builds the capital assets of the community by directly supporting the projects and by serving as the basis of the local revolving fund. The disbursement and mangement of the seed money should primarily be the responsibility of the village development committee, whose members safeguard and guarantee the

loans. This also encourages self-sufficiency and self-reliance among individuals, families and communities in sustaining and expanding local development.

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What is a revolving fund?

Revolving funds refer to the amount collected through return of loans, community development fund contributions and other resources generated at the community level. The revolving fund aims at self-reliance through mobilization of resources and community management. It also assists in sustaining CBI areas following the initial support (seed money) from the sponsoring agencies. The revolving funds are deposited in a local account managed by the community development committee in collaboration with the

technical support team. The funds are reinvested in new social and/or income-generating projects, multiplying the amount itself and also the number of beneficiaries.

 

What is a community development fund?

The community development fund is a mechanism to strengthen the sustainability of the programme and encourage direct and indirect participation at local level through contributions and sharing of benefits among community members. The community development fund comprises part of the profit earned by the beneficiaries on income generation schemes supported by the CBI.

At the time of approving any income-generation project, the community development committee and the technical support team, along with the beneficiary, determine the percentage of the contribution, depending upon the nature, feasibility and expected profit of the project. The community development fund contribution, therefore, will vary for different projects. If required, the community development committee may consider receiving community development fund contributions in non-monitory form, equivalent to the percentage agreed. The community development fund contribution is deposited in the revolving fund account and maintained locally by the community development committee. Both monetary and non-monetary community development fund contributions can be used to support community development activities, pro-poor actions, welfare initiatives, natural disaster expenditure and operational costs for maintaining the programme at community level.

 

How does cost sharing differ from profit sharing?

All social and income-generation projects in the CBI are carried out on a cost sharing basis. The beneficiaries contribute the major percentage of the initial costs of these projects. The community also shares in social projects with their efforts, materials, space and even finances. They contribute the recurrent cost of project operation, maintenance and management. Profit sharing is the contribution of the beneficiaries from the earnings they gain from the implementation of CBI-sponsored income generation projects. This becomes the community development fund, and is used to support the underprivileged segments of the community.

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Why is promotion and advocacy important for community-based

initiatives?

Advocacy is the process of educating and convincing community leaders, decision makers, relevant sectors and agencies to accept, support and commit themselves to the CBI programme. It is a continuous process, starting before the initiation of the model phase, when political and administrative commitment is obtained in order to ensure the success of the programme, and continuing during the expansion phase to ensure and maintain national support and sustainability.

 

How can partnerships be developed and strengthened?

Strong partnerships between the government and other stakeholders and civil society are required for the development of CBIs. This task of building such partnerships is achieved through continuous dialogue and the sharing of information, supported by explanation of the projects and their outcomes. The future potential for cooperation is explored in relation to common areas of interest and agendas. While advocating CBI programmes to attract new partners, adequate care should be taken to avoid conflict of interest and resistance to change.

 

Who are the major partners for community-based initiatives?

The major partners of the CBI are the community and the government. The Eastern Mediterranean Regional Office of WHO is playing a proactive role to implement these approaches through technical and material support. Besides these, other potential partners include:

• United Nations agencies such as the United Nations Development Programme (UNDP), the United Nations Children’s Fund (UNICEF), the World Food Programme (WFP), the Food and Agriculture Organization of the United Nations (FAO), the International Labour Organization (ILO), and the Arab Gulf Programme for United Nations Development Organizations (AGFUND);

• development banks such as the World Bank, Asian Development Bank, Islamic Development Bank, African Development Bank;

• bilateral donor agencies such as the UK Department for International Development, the Canadian International Development Agency, the International Fund for Agricultural Development, and the Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ);

• nongovernmental organizations (national and international);

• academic and research institutions.

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What is the role of the partners in community-based initiatives?

• Assisting the preparation of national policies and plans;

• Building the capacity of the national authorities and the communities;

• Undertaking joint actions for technical assistance and financial support;

• Fostering the flow of information, exchange of experiences and technical cooperation;

• Marketing CBI approaches, creating linkages with similar approaches;

• Supporting research and development of appropriate technologies.

 

What is the role of the community in community-based initiatives

partnerships?

• Manage the programme in order to meet the targets and goals;

• Select the cluster representatives and community development committee to represent the area;

• Conduct the survey, prioritize needs and prepare area development plans;

• Motivate families to participate in the community development;

• Participate in social development activities of the area;

• Identify poor, needy, skilled and deserving persons for income-generation projects;

• Implement the development packages to meet the targets agreed in the social contract;

• Guarantee the loans and ensure recovery is on time;

• Maintain project and financial records, including loan recoveries and deposits;

• Monitor progress and evaluate outcomes;

• Coordinate with the technical support team in the implementation and management of CBI in the area.

 

What is the role of intersectoral cooperation in community-based

initiatives partnerships?

The major determinants of health lie outside the health sector; therefore, health cannot be achieved in isolation from other sectors. It is therefore critical to involve health-related sectors in all stages of CBI management

The intent of intersectoral cooperation is to:

• mobilize, organize and assist the community in assessing its needs and priorities;

• mobilize local and national resources, and promote intersectoral collaboration in support of the CBI process;

• train the community in CBI methodologies and upgrade existing local skills;

• supervise proper resource allocation for integrated community development;

• assist in the search for, and transfer of, appropriate technologies relevant to programme activities;

• take the necessary initiatives for the expansion of the programme.

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What is the role of WHO in community-based initiatives partnerships?

The role of WHO in the implementation of CBI is catalytic in nature. At the country level, WHO and the Regional Office provide assistance in order to:

• develop models of sustainable health as part of overall local development which will serve as examples and help to ensure equity;

• prepare, in collaboration with countries, plans for launching the CBI in model areas, incorporating technical, financial, logistic and evaluation components;

• support the building up of national capacities through orientation and training activities to manage and replicate the CBI;

• encourage the development of strong intersectoral collaboration with communities, nongovernmental organizations and the private sector to promote the concept of health and equity as fundamental principles of development;

• provide financial assistance as seed money for small-scale pilot areas, covering income generation and social sector schemes;

• promote the community-based approach to other international organizations, as well as national decision makers;

• support research and development projects in the countries of the region, with particular emphasis on economic profiles and sustainability;

• enable national authorities to integrate and sustain CBIs in national development plans through gradual transformation of the role of WHO; this involves moving from active participation and financial contribution during the first phase of the CBI to mainly providing technical support to the government and people during the expansion phase.

Thanks alot to Ms Shadrokh Sirous, Technical Officer, Health for Sustainable Development, WHO,IR. IRAN