Jean-Benoît Falisse

Pour l’interview suivante de notre série sur la participation communautaire et l'Initiative de Bamako, nous avons rencontré le docteur Agostino Paganini. Agostino Paganini a une vaste expérience des soins de santé primaires et d'urgence en Afrique, un domaine dans lequel il a été actif pendant plus de quarante ans. Il était le directeur de l'unité de soutien à l’initiative de Bamako au siège de l'UNICEF. L'unité travaillait en étroite collaboration avec les pays africains qui avaient manifesté leur intérêt pour les principes de l’Initiative de Bamako. Dans la première partie de l'interview que nous publions aujourd'hui, il partage son analyse de la mise en place de l'Initiative de Bamako. La semaine prochaine, nous découvrirons son analyse de l'évolution des principes de l'Initiative de Bamako au fil du temps.

Jean-Benoît Falisse: Si je ne me trompe pas, vous avez participé à la conférence de Bamako. C'était la 38e réunion régionale africaine de l'OMS, mais l'UNICEF y a également pris part. Que faisiez-vous à ce moment? D’où l'Initiative de Bamako venait-elle?

Agostino Paganini: A cette époque, je travaillais sur un programme conjoint UNICEF-OMS de soutien nutritionnel. J'étais basé à New York et techniquement je travaillais pour l'OMS. Je n'étais pas là à Bamako, mais mon expérience de l'événement est encore vivace. Je me souviens très bien des implications organisationnelles et de toutes les retombées et les aboutissants de cette initiative de M. Grant. Bien sûr, tout ce que je vais dire dans cette conversation pourrait être biaisé, c’est ma propre expérience telle que j'ai revue et comprise au fil des années. A cette époque, le Dr Halfdan Mahler était le Directeur général de l'OMS, et M. Jim Grant était le Directeur exécutif de l'UNICEF. Tous deux étaient des dirigeants extrêmement charismatiques et puissants et ils étaient deux figures majeures du débat en santé publique et sur le développement de la santé. Mahler mettait l’accent sur les soins de santé primaires, avec une vision globale et une sensibilité aux implications politiques. Grant était beaucoup plus pragmatique, il croyait en une vision de type « guerre froide », où il y avait peu de chances de progrès importants, et il croyait donc en des étapes successives qui amèneraient l'éducation à la santé dans l'arène politique. Après la déclaration de Harare [sur le renforcement du système de district de santé fondé sur les soins de santé primaires], Grant est venu avec Bamako. Pas nécessairement, contrairement à ce que certains ont cru percevoir, comme une déclaration antagoniste à Harare, mais peut-être plus comme une déclaration plus progressive, moins « visionnaire ». Bien sûr, pour lui, c'était aussi un moyen de faire du plaidoyer pour l'Afrique parce qu'il voulait plus de ressources pour l'organisation de la santé et la survie des enfants en Afrique - et il a vu la déclaration comme un moyen de les avoir. Fondamentalement, la relation entre les déclarations de Bamako et Harare pourrait être considérée dans le contexte d'un débat intellectuel entre ces deux géants des questions de développement.

Dans le contexte de ce débat intellectuel, qui faisait pression pour l'Initiative de Bamako? Quels ont été les principaux points de consensus et de divergence entre les pays et / ou organisations?

Aux côtés des ministres africains, l'UNICEF a encouragé et fait pression pour ce genre de déclaration - pour laquelle l'OMS n'était pas particulièrement enthousiaste. En fait, même certaines parties de l'UNICEF n'étaient pas très heureuse à ce sujet. Au niveau politique, ce qui était évidemment le plus difficile à accepter c'était la question des frais d'utilisation et du partage des coûts. L'UNICEF et M. Grant, sur base de ce qui se passait au Bénin et dans de nombreux pays africains, s'est rendu compte que le payeur réel en matière de santé n'était pas le gouvernement, pas plus que le bailleur, c’était le foyer, le ménage. La majorité des dépenses étaient payées directement de la poche des foyers. Il s'agissait donc de «co-financement». Comme certaines personnes identifiaient cette idée d'avoir les gens co-financer leurs services de santé avec la vision de la Banque Mondiale sur les frais d'utilisation, le débat est devenu très idéologique. Dans la proposition de l'Initiative de Bamako, il était suggéré que les gens paieraient quelque chose de leur poche. Si les bailleurs aidaient à améliorer les services en termes d'infrastructure, de disponibilité des médicaments, de formation et de supervision du personnel et de mécanismes de suivi, on aurait tort de considérer que les gens ne doivent pas contribuer du tout au coût de la prestation de services (même si c’est en payant moins que le coût réel). Cet argent resterait avec les gens qui avaient payé, au niveau du centre de santé, et il serait contrôlé par la communauté. C'était l'hypothèse. La réaction de l'autre côté a été de crier à la privatisation et d’appeler cela un moyen de faire payer les gens pour la santé, alors que la santé est un droit humain fondamental qui ne peut être vendu.

Une partie de l'Initiative de Bamako porte sur  la participation communautaire. Dans l'entrevue avec Susan Rifkin, elle explique que son intérêt pour la participation de la communauté a commencé avec l'expérience des médecins aux pieds nus en Chine. Y a-t-il quelque chose de semblable en Afrique? Quelque chose qui a convaincu les gens à Bamako?

Dans l'unité que je gérais à New York, tout le monde était absolument convaincu que le plus grand changement politique qu’a apporté l’initiative de Bamako n'était pas d’abord lié à l'argent mais à l'effort pour renforcer les communautés dans leur contrôle des centres de santé et de leur personnel. Nous avions l'impression que le personnel de santé avait alors en quelque sorte privatisé le système de santé. Le système de santé ne fonctionnait plus, il s'agissait d'un secteur privé non-réglementé où vous aviez à payer pour tout, sans aucun contrôle sur la qualité ou sur l'utilisation de l'argent. Pour nous, l'Initiative de Bamako était un moyen de renforcer la capacité des gens à faire partie et prendre part à la gestion du centre de santé. Il ne s'agissait pas de la gestion technique du centre de santé, mais bien des aspects de  «gouvernance». Est-ce que cela a été un succès? Dans certains endroits, comme au Mali au début, c'était assez bon. Pourtant, j'ai eu l'impression que, après un certain temps, l'Initiative de Bamako a été interprétée/considérée par certains des ministères de la Santé comme une excuse pour faire payer tout ce qu'ils voulaient sans aucun contrôle par la communauté sur l'argent.

Au niveau communautaire, qu’est ce qui était en place au moment de la déclaration de l'Initiative de Bamako?

Dans certains pays, il y avait des comités de santé, mais ces comités de santé n’avaient jamais de contrôle sur aucune ressource. Dans ces pays, on pourrait partir de ces comités. Cependant, dans d'autres pays comme la Guinée après Sékou Touré, il n'y avait rien. Le système de santé avait été détruit et avec le ministère de la Santé de la Guinée, des comités de gestion ont été mis en place. Ce fut le début d’un mouvement qui allait donner de la substance à la participation communautaire à travers le co-financement et la cogestion des centres de santé. Tel était le langage que nous voulions utiliser, non pas « recouvrement des coûts », mais « cogestion communautaire et co-financement ». Cela a été mis en œuvre dans différents pays et sous des étiquettes différentes. Il s'agit d'un processus fastidieux qui nécessite beaucoup d’appui au niveau communautaire.

L'Initiative de Bamako pourrait être décrite comme ayant trois piliers: (1) participation communautaire, (2) mécanismes d'autofinancement et (3) un approvisionnement régulier en médicaments. Vous avez déjà abordé les deux premières questions, pourriez-vous dire un mot sur l'approvisionnement régulier en médicaments?

L'expérience sur le terrain est que les centres de santé n'étaient pas utilisés et leur utilisation était incroyablement basse pour deux raisons: (1) une était lié à l'infrastructure et au comportement du personnel qui étaient perçus comme 'pourris' et donc les centres de santé déclinaient et l'autre (2), c'est qu'il n'y avait pas de médicaments. Les médicaments sont perçus par les utilisateurs comme un élément clé dans le processus thérapeutique, et c'est fondamentalement vrai où que vous soyez. Les gens dépensaient leur argent sur le marché non réglementé ou n'importe où ailleurs. Il était évident que les médicaments devaient être disponibles dans le centre de santé. Le centre de santé devait devenir le lieu non seulement pour les soins préventifs, mais aussi pour les services curatifs. Il ne faut pas oublier que la principale préoccupation de l'UNICEF à cette époque ce n'était pas des soins curatifs, c'était principalement la vaccination et la survie des enfants (qui sont pour la plupart liés à des soins préventifs). Toutefois, amener les personnes au centre de santé en raison de la disponibilité des médicaments pour leurs besoins curatifs était une façon de travailler sur le côté préventif.

Je prends un exemple: la survie des enfants et le paludisme sont deux problèmes très évidents de l'Afrique qui n'étaient pas très bien pris en charge. Il y avait des programmes verticaux avec des antibiotiques et des médicaments antipaludiques, mais ils n'étaient pas suffisants. Avoir un centre de santé fonctionnel était donc vu par nous comme un moyen de tendre vers une vision beaucoup plus globale des soins de santé primaires. C'était un processus graduel par lequel les staffs de santé étaient formés et les centres de santé améliorés grâce à des investissements des bailleurs de fonds et du gouvernement. Les frais de fonctionnement qui n’étaient pas couverts par le gouvernement étaient cofinancés par la communauté. La clé était d'avoir un comité qui supervise la gestion de l'argent afin qu'il y ait de la redevabilité envers le public. La participation communautaire était considérée comme un moyen de faire en sorte que le personnel médical et administratif rende compte à la population. Ce système de monitoring était fondamental car il permettrait aussi au comité de direction et au personnel d'avoir une vue sur la couverture et la vaccination, le nombre de visites, le nombre de femmes qui ont accouché, etc. De cette façon, ils pouvaient se fixer des objectifs, discuter entre membres du comité et personnel de santé des goulots d'étranglement dans le système et, en fin de compte, améliorer la durabilité, l'accès et l'utilisation correcte des services.

(à suivre)

The next interview of our series on community participation and the Bamako Initiative is with Dr. Agostino Paganini. Agostino Paganini has an extensive experience of primary health care and emergency health care in Africa, an area in which he has been active for over forty years.  He was the manager of the Bamako Initiative Support Unit at the UNICEF HQ. The unit worked closely with African countries that had shown interest in the principles of the Bamako Initiative. In the first part of the interview we publish today, he shares his analysis of the set-up of the Bamako Initiative. Next week, we will discover his analysis of the evolution of the Bamako Initiative principles over time.

Jean-Benoît Falisse: If I am correct, you took part to the Bamako conference. It was the 38th African Regional Meeting of WHO but UNICEF also became involved. What were you doing at that time? Where was the Bamako Initiative coming from?

Agostino Paganini: At that point of time, I was working on a joint UNICEF-WHO nutrition support programme. I was based in New York and technically working for WHO. I was not there in Bamako but my experience of the event is still vivid. I remember quite well the organisational implications and all the fall-outs of this initiative of Mr. Grant. Of course, everything in this conversation could be biased, it is my own experience that I have revisited and understood over the years. At that time, Dr. Halfdan Mahler was the Director General of WHO and Mr. Jim Grant was the Executive Director of UNICEF. Both were extremely charismatic and powerful leaders and they were two major figures in the public health and health development debate. Mahler had a focus on primary health care issues with a global vision and sensitivity to political implications. Grant was much more pragmatic, he believed in that sort of 'cold war vision' where there were little chances for big progresses and therefore he believed in incremental steps, bringing up health in the political arena. After the Harare declaration [on strengthening the district health systems based on Primary health care], Grant came up with Bamako. Not necessarily, as perceived by some, as a declaration antagonistic to Harare's but maybe as a more incremental, less 'visionary', declaration. Of course, for him it was also a way to call for Africa because he wanted more resources for health organisation and child survival in Africa and he saw the declaration as a way to have them. Basically, the relation between the Bamako and Harare declarations could be seen in the context of an intellectual debate between these two giants of developmental issues.

In the context of this intellectual debate, who was pushing for the Bamako Initiative? What were the main points of consensus and divergence between the countries and/or organisations?

Alongside with the African Ministers, UNICEF promoted and lobbied for this kind of declaration – for which WHO was not especially keen. Actually, even some parts of UNICEF were not happy about this. At the policy level, what was obviously the most difficult to accept was the issue of user fees and cost-sharing. UNICEF and Mr. Grant, on the basis of what was happening in Benin and many African countries, realised that the real payer in health was not the government any more, it was not even the donor any more, it was the household. The majority of expenditures were paid out-of-pocket. The issue was therefore 'co-financing'. Yet, some people identified this idea of having people co-financing their health services with the World Bank vision on user fees and the debate became very ideological. In the proposition for the Bamako Initiative, it was suggested that people would pay something out-of-pocket. If donors were helping making the service better in terms of infrastructure, drugs availability, training and supervision of staff and monitoring mechanisms, it would be wrong that people do not contribute to the cost of delivering services (although paying less than the actual cost). However, that money would stay with people who paid, at the health centre level, and it would be controlled by the community. That was the hypothesis. The reaction from the other side was to call this opening the door to privatisation and a way to have people pay for health when health is a basic human right which cannot be sold.

Part of the Bamako Initiative is about community participation. In the interview with Susan Rifkin, she says what sparkled her interest in community participation was the experience of barefoot doctors in China. Was there anything similar in Africa? Something that convinced people in Bamako?

In the unit I was managing in New York, everybody was absolutely convinced that the biggest political change that Bamako initiative was bringing was not the money but the effort to empower the community in controlling their health centres and staff. We had the impression that the health staff had basically privatised the health system. The health system was not functioning any more. It was an unregulated private sector in which you would have to pay for everything without any control on the quality or the use of the money. For us, the Bamako Initiative was a way to strengthen the capacity of people to be part of and take part in the management of the health centre. It was not about the technical management of the health centre but about the ‘governance’ aspect of it. Was it successful? Well, in certain places like in Mali in the beginning it was quite good. Yet, I had the impression that after a while the Bamako Initiative was interpreted/considered by some of the Ministries of Health and staffs as an excuse to charge whatever they wanted with no control by the community on the money.

Community-wise, what was in place at the time of the Bamako Initiative declaration?

In some countries, there were health committees but these health committees never controlled any resource. In these countries, we could start from these committees. However, in other countries such as Guinea after Sékou Touré, there was nothing. The health system had been destroyed and with the Ministry of Health of Guinea, managing committees were set up. It was the beginning of giving substance to community participation through the co-financing and co-management of the health centres. That was the language we wanted to use; not ‘cost recovery’ but ‘community co-management and co-financing’. It was implemented in different countries and under different labels. This is a labour intensive process that requires a lot of assistance at the community-level.

The Bamako Initiative could be described as having three pillars: (1) community participation, (2) self-financing mechanisms and (3) regular supply of drugs. You already touched the first two issues, could you say a word about the regular supply of drugs?

The experience on the ground was that health centres were not used and their utilisation was incredibly low for two reasons: (1) one was linked with the infrastructure and the behaviour of the staff which were perceived as rotten and so the centres were going down and the other (2) was that there were no drugs. Medicine is perceived by the users as the key element in the therapeutic process, and this is basically true wherever you are. People were spending their money on the market, buying drugs in the unregulated market or anywhere else. It was obvious that medicine had to be available in the health centre. The health centre had to become the place not only for preventive care but also for curative services. Do not forget that the main preoccupation of UNICEF at that time was not curative care; it was mainly immunisation and child survival (which are mostly linked to preventive care). However, having people coming to the health centre because of the availability of medicine for their curative needs was an important key for preventive purposes.

I take an example: child survival and malaria were two of Africa’s very obvious problems which were not very well addressed. There were vertical programmes with antibiotics and antimalarial drugs but they were not sufficient. Having a functional health centre was seen by us as a way to move towards a much more comprehensive vision of primary health care. It was a gradual process through which health staffs were trained and health centres improved thanks to investments from donors and the government. The running costs that were not covered by the government were co-financed by the community. The key was to have a committee which would oversee the management of the money so that there was public accountability. Community participation was seen as a way to obtain accountability from the medical and managerial staff. Monitoring was also a pillar in the system because it would allow the managing committee and the staff to have a view on coverage and immunisation, number of visits, number of women who were delivering babies, etc. This way they could set objectives, discuss between the members of the committee and the health staff, find bottlenecks in the system, and eventually improve the durability, access and correct utilisation of health care.

Jean-Benoît Falisse


This is the second part of the interview with the huge community-driven reconstruction programme 'Tuungane' of IRC in Eastern DRCongo. We now turn to issues around community participation in health care.

JBF: Let’s now turn to health. If I understand correctly, the communities had the choice of allocating the money coming from Tuungane to the sector of their choice. Was health-care a much sought after sector? Did it emerge as a priority? What were the main challenges?

VQ & FD : On average, health is chosen second most often by communities in the program, after education. Tuungane dedicated over $ 5 million to the health sector in the first phase (2007 to 2010). Schools were often the communities’ first choice because in general the education sector currently receives much less support than the health sector. In addition, the health sector is more regulated than others in DR Congo: health facilities must be registered and most importantly, have qualified staff to operate.

For the rapid impact projects at the village level in phase I, health was chosen third most often with 223 projects put in place and $484,000 invested. Communities most often chose to build, renovate or equip their health center or maternity ward. Among the larger community-level projects, health was chosen more often than at the village level. As a result, 69 major health infrastructures were built with an investment of nearly $ 5 million. Equipment needs were also considered important at this level, and nearly $ 10,000 per centre went into purchase of things like solar panels, and other electrical equipment to ensure a power supply, given that electricity is not common in rural areas.

A challenge that remains in the end is the ongoing management and functionality of these infrastructures. Without drugs, or qualified staff that are properly supervised, the facilities cannot provide quality service.  To work further on this, the current Tuungane design ensures links with line ministry officials, and with other donors and programs working in the area to improve the sustainability of these health-care facilities.

JBF: IRC has also chosen to support health development committees (CODESA), why did you choose this approach? Can the CODESA really work in the context of humanitarian emergency of Eastern DRC?

VQ & FD : The Health Development Committee (CODESA) is really the program’s entry point to understand the real challenges which health care workers faces at the local level. Generally, these challenges are not limited to the lack of infrastructure but also involve problems of financial management and logistics.

Often, the CODESA is not in a position to play the role they are meant to, that of intermediary between the community and the health service providers. Their members lack both the knowledge of their roles and responsibilities and means to fulfill them.  It is not necessarily the humanitarian context is at the root of these limitations, but rather longstanding issues of low levels of education, weak management structures and lack of resources. Even in the Haut Katanga district of Katanga province in the south of the country which is not in a site of humanitarian emergency, the CODESAs are not effectively playing their role.

In principle, the CODESA is supposed to co-manage the health resources meaning: participate in developing planning of health services in the area, monitor and evaluate the health care services, schedule meetings to consult the population and make joint decisions related to service provision. According to its mandate, the CODESA is also supposed to mobilize local resources, develop small-scale projects to improve service provision, ensure public hygiene, and do public education and promotion of key health principles and behaviours.

When the community chooses health as their priority sector, Tuungane works to strengthen the CODESA. Members of the CODESA are integrated into the Village Development Committee (VDC) so that they can provide technical advice, and also benefit from the training provided by the program and liaise between the VDC and the health personnel. As such, they actively participate in identifying implementing and managing the community project. In its second phase, the program provides a grant of $ 24,000 per community. This is divided into two parts. The first 95% is used to rehabilitate and equip existing health infrastructure. The 5% portion of the grant which remains is meant to spent on improving quality aspects of the service, that is, to resolve issues and problems related to the governance and management of the health facility .

JBF: IRC has also using a tool called the community score card. Is this a relatively known strategy of participation? What do you conclude from your experience? What is specific to your scorecard?

VQ & FD : To imbue the relationship between service providers and beneficiaries with accountability, the program first provides communities with information on the norms and standards as defined in country-wide health policies and strategies. Then we introduce a tool for evaluating and monitoring the service as delivered in the community: the Community Scorecard. Through this scorecard process, the community assesses the performance of the service provided in their local school or health center. After the scoring, the services users and service providers work together to develop a joint plan for service improvement. This so-called community scorecard methodology was developed by the World Bank.

Our first experiences with the scorecard mechanism showed that the population and even the health care workers had difficulty assessing aspects not related to the infrastructure, i.e. the non-tangible aspects of the service provision. They focused primarily on the poor condition of buildings and the lack of equipment. There are of course many more elements that come into play to get good health care. Therefore, the program pre-selected four indicators for communities to consider as part of the scoring: (i) access to care, (ii) equity or the fair treatment of all patients, (iii) participation of the Health Development Committee (CODESA ) in the financial management of the infrastructure, and (iv) their overall impression of the quality of care.

Results following use of the scorecard show some initial signs of improvement taking place in communities such as better access to information about health care services, and a greater understanding of the roles and responsibilities among all parties involved. Through the discussions, the community members and the CODESA build an understanding that they are entitled to certain service standards, but they also have a role to play in ensuring quality service. For example, they have a right to access to quality health care, but they also have a duty to behave responsibly in the prevention of epidemics. The CODESA knows it has the right to audit the budget of the health facility, but it also has a duty to report and consult the public on major decisions taken regarding health services in the area.

In addition, the CODESA and representatives of the people realize that they are potentially allies in the seeking service improvements, because they have certain interests in common. Indeed, they realize if external partners were not intervening in the delivery of health care services, the health facilities and their staff would be left to fend for themselves and just do their best to survive with minimal means. To address this, the program help communities and frontline services providers go together to meet with line ministry representatives, such as the Chief Medical Officer and Public Health Inspectors responsible for the jurisdiction. In dialoguing with these higher-level authorities, the community representatives and service providers endeavour to (i) obtain the higher authorities’ approval for the project they have chosen for the sector, (ii) raise awareness of the real problems and challenges facing the community, and (iii) solicit their support in finding joint solutions to improve health services at the village level.

Since 2007 the program has made great strides in terms of engagement with the Congolese administrative and line ministry authorities. It strives to create space for a productive dialogue between government officials and village-level constituents to improve the quality of service provision at the village level..

For the two following posts of our series, I had the opportunity to talk to François Defourny (Deputy Director - Governance) and Vera Quina (National Quality Manager) who participated actively in implementing the Tuungane projects in Eastern DRC. Tuungane (I and II) is probably the largest community-driven reconstruction projects ever undertaken. The question raised here is about participation in difficult environments and in the context of international aid. In the first part of the interview, they discuss the program in general, which does not focus exclusively on health. In the second part, I asked them to explain in more details the health component of the project.

Jean-Benoît Falisse:  The Tuungane project is probably one of the biggest projects of community-driven reconstruction (CDR) never implemented. Could you tell us how things started? Why has IRC chosen such approach?

Vera Quina & François Defourny: In 2006, the Democratic Republic of Congo turned a page of its history. The first free elections since its independence meant the end of a difficult transition process that ended a long period of unrest which  ultimately took the lives of nearly 5.4 million people; the deadliest conflict since World War II. The program 'Tuungane' was designed to fit into the context of post-conflict reconstruction. The initial objective was to improve the stability and living conditions of communities affected by the war in eastern Congo.

The approach chosen was to work on village-level reconstructions but to have them managed by the communities themselves (Community-Driven Reconstruction – CDR). The communities would decide which type of reconstruction was a priority. A key assumption of this approach is that people know best their priority needs. Through the CDR method, Tuungane sought to respond appropriately to the basic needs of a large population affected by the conflict, but still taking into account the particularities of each community.

A second key element of this approach is called 'learning by doing'. By working together to identify, setup and manage the reconstruction projects, communities discover the virtues and demands  of good governance. They experience the   democratic mechanisms of representation, procurement, accountability and transparent collective management. The exercise aims to both strengthen cohesion within communities by bringing people together around a common project and further stimulate the population’s demand for good governance from service providers and government.

It is therefore through a community-led reconstruction approach that Tuungane has sought to meet priority needs of communities while promoting social cohesion, democratic governance and local economic recovery.

JBF: There were several phases of Tuungane, how is that different approaches were, what lessons have you learned from the first phase?

VQ & FD : In 2007, Tuungane began working in three eastern provinces of Congo (South Kivu, Maniema, Katanga) and this first phase lasted until 2010. The second phase began in 2011 and will last until 2014, adding the province of North Kivu as a new location for the program.  In both phases, Tuungane mobilizes communities to develop local governance structures, establish development plans and organize resources for the implementation of their priority projects. Through this process, the program aims to contribute to stability in the region and promote a better understanding and practice of the principles of good governance: transparency, participation, inclusion and accountability.

During the first phase of Tuungane, from 2007 to 2010, communities received two grants: the first was $ 3,000 for rapid impact projects at the village level and the second was $ 50,000 - $ 75,000 at the community level, which grouped several villages together. Each of these grant amounts was designed to meet the needs identified by the entire population. In all, 1812 rapid impact projects were undertaken at the village level and 346 were developed at the larger community level. In both cases, education was chosen the most often, ahead of health and water, sanitation and hygiene (WASH) projects.

The program learned a lot in its first phase that informed the design of the subsequent phase. For example, in phase II the program works exclusively at the village level, which is considered more "natural" grouping than the larger community groupings previously covered. The amount of funding to the village level has significantly increased; from $ 3,000 to $ 24,000. New projects are supposed to be more integrated into the indigenous structure, more sustainable and more comprehensive. In the second phase, the reconstruction of infrastructure is only a part of the effort to improve services.  The new approach is both more holistic, it is also more aligned with national policies, and with DRC local development and decentralization strategies. In the provinces of Katanga and Maniema, a new component was launched in Phase II which was specifically designed to work with decentralized local governments and stimulate interaction between them, communities, and decentralized technical services.

JBF: With Tuungane, villages create a new development committee. Isn't this creating yet “another committee” in these communities? How does the Tuungane program coordinate with existing community participation initiatives in the field (committees of parents / students, health committees, etc.)?

VQ & FD : First it is important to note that while DRC is in the process of decentralization, this process is far from reaching fruition.  Local elections have not taken place yet. This means that at the local level, there is no truly representative body that can benefit from the support of the program. This is the reason why Tuungane organizes elections where people vote by secret ballot, to ensure that the “Village Development Committee” is truly representative of the whole community.

In its second phase since 2011, the Tuugane II program continues to work through village committees but they are now integrated with existing players involved in the provision of public services. These include supply-side service providers such as the school principal or the head nurse, and the demand-side health and education committees which already exist in all communities and are supposed to represent the interests of the population in these sectors. For example, if health or education is chosen as the priority sector  by the community, the Tuungane elected Village Development Committee (5 members) is now joined by the existing health or education sectoral committee members to form a hybrid committee of 10 members.

These sectoral committees, the Parents Committee (COPA) and the Health Development Committee (CODESA), are recognized under  Congolese law. Their mandate is to co-manage the social infrastructure in the sector (e.g. schools, health centers) and monitor the quality of service that these institutions offer. In principle, they must also be accountable to the community. However, even if COPA and CODESA are formally recognized by law, their capacity to represent the population’s interest is sometimes inadequate (e.g. their terms in office have lapsed or their members are co-opted by providers, etc.).  Overall, they do not always play the role assigned to them in monitoring service provision, and making demands of service providers to render account and improve the service. In such cases, when the COPA or CODESA is not really fulfilling its role as a representative of the population, Tuungane liaises with the authorities in the sector to organize new elections and restart the committee on solid ground.

After the experience of Tuungane 1, the program decided it was essential to continue having a committee elected by the people to ensure a 'social contract', an accountability relationship,  to promote good governance. With this in place, if the committee does not respond to the community’s needs, or siphons funds meant for the community project, the population is in a position to question, sanction or remove the committee. In fact, Tuungane as a program requires that that the population as a whole responds to any instance of missing funds. The community must convene a general assembly to discuss the situation, and if they do not take appropriate action to recover funds including dismissal of some or all of the committee representatives responsible for the mismanagement, the community as a whole can be excluded from the program.

Finally, the first phase of the program also showed that village leaders had a high degree of acceptance of the elected village committees. They saw them as legitimate and recognized it as useful to have a committee chosen by the community to manage the funds.

JBF: The impact study conducted by Columbia University and published in June did not find much impact of the program. At the same time, a recent article by Tim Harford (The Undercover Economist) published in the Financial Times highlights Tuungane's achievement in bringing assistance to beneficiaries. What is your perspective on the impact and success Tuungane after several years in the project?

VQ & FD : The Columbia University study confirmed above all that the program had been implemented correctly, in accordance with what was originally planned. It showed that the funding from DFID, together with IRC’s technical supervision, had successfully worked with communities to rebuild infrastructures they considered important for their development. In total, 1531 committees were elected and trained to select and manage priority projects. This led to the construction or rehabilitation of 2,297 classrooms and 241 health centers, drinking water 1014 facilities, etc. Given the particularly difficult context of eastern DRC, this is no small achievement.

Then at the impact level, the study focused primarily on the whether Tuungane had changed certain behaviours for long term effect. It is true that the study found relatively little evidence of significant program impact on the practices of governance, social cohesion and economic recovery. But to be honest, this is not so surprising. The evaluation focused on effects after an intervention period of about 18 months in each community. It was probably a bit presumptuous to think that such fundamental changes could happen within Congolese society in such a short time period.

On the other hand, the evaluation highlighted some shortcomings in the design of the first phase; the level of investment per capita reflected in the grant sizes given to communities was rather low, and arguably too low induce a real change. The program may also have focused too much on rebuilding infrastructures rather than on improving the basic services, meaning the quality aspects of the service that come with the infrastructure. We have taken this feedback on board significantly adjusted the program in the second phase, launched in January 2011.

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Jean-Benoit Falisse


Dans le cadre de notre série sur l’Initiative de Bamako, Jean-Benoît Falisse a interviewé Sassy Molyneux (Oxford University Research Professor et chef d’unité) qui travaille avec le programme KEMRI-WT à Kilifi, au Kenya. Elle possède une vaste expérience de recherche sur la participation et la ‘redevabilité’ communautaire en Afrique de l’Est et a récemment co-écrit une revue de la linéature sur le sujet (community accountability at peripheral health facilities: a review of the empirical literature and development of a conceptual framework).

Jean-Benoît Falisse : Qu'est ce qui a déclenché votre intérêt pour la « redevabilité communautaire » (community accountability) dans la santé? Pourriez-vous m'en dire un peu plus sur les activités de recherche KEMRI-WT sur cette question?

Sassy Molyneux : Je suis intéressée par les interactions entre les communautés et les systèmes de santé depuis des années ; j'ai commencé à travailler sur le sujet lors de ma recherche doctorale menée sur la côte kényane dans les années 1990. La participation communautaire et l'autonomisation ont longtemps été soulignées comme étant des approches importantes pour assurer un prix abordable et adapté localement, de même que des bons services préventifs et curatifs. Cependant, atteindre cet objectif est clairement loin d'être simple. Une approche impliquant les communautés qui a été promue au Kenya comme dans beaucoup d'autres pays a été l'initiative de Bamako. Au Kenya, elle comprenait la création de pharmacies communautaires. Malheureusement ces pharmacies étaient en souffrance au moment de mon travail de terrain de doctorat. Au cours des années, il y a également eu de nombreux efforts pour promouvoir la participation communautaire dans les soins de santé au Kenya, via des comités au niveau des villages et des formations sanitaires. Ces comités ont été l'objet de discussions lors de ma thèse de doctorat. Les gestionnaires de santé les présentaient comme un énorme succès, comme «l'étalon-or», mais il est apparu que lorsque les frais d'utilisation ont été réduits au Kenya dans les années 2000, leur rôle a été affaibli. Ils avaient moins de ressources sur lesquelles ils avaient leur mot à dire. Je pouvais alors voir qu'il y avait un grand potentiel, mais aussi des défis, pour choisir et travailler avec des «représentants» de ces communautés complexes dans des systèmes de santé organisés de manière très hiérarchique.

J'ai de plus en plus commencé à entendre parler de «responsabilisation des communautés», une chose qui a été et est encouragée pour toute une gamme de fins instrumentales et intrinsèques. J'ai été intrigué de ce que «cela» était vraiment, et comment cela différait ou non de la participation communautaire. Je suis intéressée à comprendre davantage la façon d'impliquer les communautés compte tenu de la difficulté de les définir, de la nature technique de nombreux aspects de la prestation des services de santé, et des relations de pouvoir complexes au sein des communautés et des systèmes de santé, et entre les prestataires de santé et les membres de la communauté. En travaillant dans un programme de recherche multidisciplinaire, je me suis également intéressée aux aspects théoriques et pratiques de l'idée de redevabilité envers la communauté au sein du système de santé à l'information et l'implication de la communauté dans les activités de recherche biomédicale.

Aujourd'hui, la plupart des auteurs et des praticiens de la santé publique parlent de «responsabilité» communautaire plutôt que de «participation» communautaire (comme on le faisait au moment de l'Initiative de Bamako). Est-ce vraiment un concept différent?

Ma compréhension est que, dans la participation communautaire, des individus ou leurs représentants influencent des éléments des systèmes de santé en faisant entendre leur voix et opinions auxquels une réponse est ensuite donnée, donc il y a un élément de redevabilité. Cela nécessite une action et des interventions malgré les défis et des systèmes qui supportent ces attitudes. Je pense que la participation communautaire est un terme plus large, qui pourrait bien aussi inclure ce que je viens de décrire [la redevabilité]. Les deux termes [participation et redevabilité] sont utilisés différemment et se chevauchent. Peut-être le plus important, quelle que soit le terme ou à travers les deux termes, est de considérer la profondeur de l'engagement communautaire, soit les niveaux d'un véritable renforcement (empowerment). De nombreux auteurs ont fait valoir que la participation communautaire peut aller de la simple information donnée aux communautés à une extrémité du spectre, à la concertation, à l'influence de la communauté et finalement au contrôle à l'autre extrémité. Ceci est important pour souligner que la mise en place de possibilités d'interaction avec les membres de la communauté ne conduit pas nécessairement à plus d'influence ou de contrôle par la communauté. En outre, il est possible d'avoir des initiatives de participation communautaire «manipulatrices» ou «symboliques» qui apportent un soutien qui n'est que de façade à une idée à la mode. C'était ma reconnaissance à la fois du potentiel mais aussi des défis et même peut-être des effets pervers liés à la responsabilisation des communautés qui m'a amené à être plus curieuse à propos de ce domaine.

Dans une revue de la littérature récente (2012), vous soulignez qu'il n'y a pas beaucoup d'études sur l'impact des mécanismes de redevabilité communautaire. Quelle en est la raison? Savons-nous réellement ce qui fonctionne?

Il y a une mise en garde légère à apporter par rapport à cette conclusion, car nous nous sommes concentrés plus précisément sur les mécanismes de redevabilité communautaire au niveau des services de santé périphériques. Il y aura donc un corpus (probablement plusieurs) de littérature que nous ne considérions pas et qui traite de la responsabilisation des communautés en dehors des mécanismes spécifiques liés aux formations sanitaires. De plus, il est probable que des recherches qui ont été menée à ce sujet aient été rédigées dans des rapports qui ne sont pas (facilement) accessible au public.

Une partie du manque est, je pense, liée aux initiatives de renforcement de la redevabilité qui font souvent partie d'interventions très complexes menées en matière de santé et de systèmes sociaux complexes. Lorsque cela est combiné avec les difficultés à définir et à mesurer de nombreux aspects de la responsabilisation des communautés (par exemple la profondeur de l'implication ou l'engagement, les niveaux d'habilitation et des changements subtils dans les relations de pouvoir), la conception et la réalisation de stratégies d'évaluation pertinentes devient très difficile. Il existe donc un besoin pour des approches méthodologiques plus innovantes; il faut aller au-delà des simples expériences randomisées ou des méthodologies qualitatives standards. C'est un défi qui est reconnu dans les systèmes de santé, on voit par exemple de plus en plus de promotion de recherches-actions (participative) et d'intérêt pour l'intégration des approches réflexives et délibératives dans les évaluations afin de s'assurer que les connaissances implicites des acteurs soient prises en compte.

La majorité de la littérature sur le sujet s'intéresse aux comités de santé qui gèrent des formations sanitaires. Pourquoi en est-il ainsi? Quels sont les autres mécanismes de 'redevabilité communautaire' existant? Lequel vous semble particulièrement prometteurs?

Comme je l'ai mentionné ci-dessus, nous nous concentrions très précisément sur les mécanismes de redevabilité liés aux structures de santé périphériques, ce qui pourrait en partie expliquer ce phénomène. Bien sûr, il existe de nombreuses autres formes de groupes communautaires qui militent pour l'amélioration de la santé, qui ne sont pas spécifiquement liés aux formations sanitaires, y compris ceux qui ont été plus spontanément initié et mis en place par les membres de la communauté eux-mêmes. Dans les formations sanitaires, il y a d'autres interventions telles que : les chartes des droits des patients (pour promouvoir la sensibilisation aux droits et intérêts en exigeant le changement), le partage de l'information, les boîtes à idées/suggestions (pour réduire les asymétries d'information et d'encourager les idées et les opinions soient exprimées) et d'autres mécanismes qui peuvent être vaguement qualifiés de surveillance communautaire. Ceux-ci impliquent souvent des membres de la communauté et les prestataires de santé qui décident ensemble des domaines d'action prioritaires / changement, de la mise en œuvre du changement, du suivi communautaire du progrès, et du partage des informations avec le public sur les progrès des formations sanitaires par rapport à des indicateurs sélectionnés. Ces initiatives sont potentiellement très intéressantes. Le défi devient alors de partager les enseignements dans différents contextes et niveaux du système de santé, et d'encourager la propagation et l'adaptation des initiatives réussies dans d'autres lieux.

À propos de la validité externe. Que pouvons-nous apprendre d'expériences nécessairement locales de responsabilisation de la communauté? Quelle est l'importance des facteurs contextuels et culturels pour expliquer le succès des mécanismes redevabilité envers la communauté?

Je pense que nous avons vu de notre examen que si même si, bien sûr, les initiatives de responsabilisation communautaire doivent être adaptées au contexte local et réactives, il y a des idées maîtresses qui émergent de façon transversale et qui sont pertinentes dans tous les sites. Une forme de généralisation théorique est donc utile pour des initiatives dans d'autres contextes. Ainsi, dans notre travail nous avons par exemple vu l'importance de la clarté du rôle des membres des comités et de leurs responsabilités, de la disponibilité de ces personnes et de l'accès à l'information. Il est également important de souligner la nécessité d'examiner attentivement la rémunération et les autres formes d'incitations pour les représentants de la communauté, les défis de l'asymétrie entre le personnel de santé et les représentants de la communauté en matière de ressources et d'énergie et l'importance de construire une relation de confiance. Bon nombre de ces aspects sont à leurs tours liées à l'intérêt réel et à la valeur que le système de santé accorde à la participation communautaire.

Vous plaidez en faveur de méthodes de recherche mixtes pour explorer les mécanismes de redevabilité communautaires. Pourriez-vous nous expliquer comment les approches qualitatives et quantitatives se complètent les unes les autres lors de l'exploration des questions de redevabilité communautaire? Est-ce que l'utilisation d'une seule méthode serait nécessairement plus incomplète ou plus faible?

Je pense que de bonnes approches qualitatives peuvent être appropriées pour explorer les complexités que j'ai décrites ci-dessus. Un défi est de donner aux auteurs assez d'espace dans l'écriture, en particulier dans les revues scientifiques, pour convaincre les lecteurs de la profondeur méthodologique et analytique de leurs études. Certaines études qualitatives semblent être des discussions de groupe relativement superficielles et des entretiens individuels à travers lesquels il est très difficile de rendre justice à notre sujet. Compléter ces approches avec des méthodes quantitatives - lorsque cela est possible et pertinent par rapport à une question spécifique - peut aider à donner une meilleure vue d'ensemble de la taille des enjeux / impacts. Cela peut être également utile dans la diffusion de la recherche; dans l'élaboration d'initiatives destinées à des auditoires particuliers. Comme indiqué plus haut, en incorporant plus de "nouvelles" approches dans les évaluations qualitatives ou mixte -par exemple des approches participatives, des activités délibératives et des réflexions avec les d'acteurs clés- les travaux de recherche pourraient être renforcés. Ici, je pense qu'il est nécessaire de continuer à partager des idées sur la façon de renforcer la fiabilité et la transférabilité des données recueillies grâce à ces approches méthodologiques, et de convaincre les autres de cette qualité dans le but d'éclairer les politiques et les pratiques. Il existe de nombreuses initiatives communautaires de responsabilisation mise en œuvre tout le temps - soit initiées et soutenues par les collectivités ou les représentants eux-mêmes, ou par les gouvernements et d'autres acteurs. Trouver de nouvelles façons de documenter et d'évaluer leurs activités de façon convaincante pour les rapporter  à des publics clés serait utile. Il faudrait pour cela une analyse non seulement des réussites, mais aussi des défis et des échecs, et des raisons de ces résultats.

Il semble qu'il y ait un renouvellement récent de la recherche sur la participation/redevabilité communautaire. Êtes-vous d'accord? Quels sont, pensez-vous, les principaux domaines restants de la recherche sur la 'redevabilité' envers la collectivité (dans le domaine de la santé)?

Je pense que la participation communautaire / la redevabilité apparaît comme un domaine d'intérêt et d'attention au niveau politique et pratique, et donc aussi dans la recherche. Ceci est peut-être aidé par la nouvelle terminologie! Mon domaine d'intérêt aujourd'hui, en m'appuyant sur des recherches antérieures, est de savoir comment les formes de redevabilité externe ou communautaires tels que les comités de santé interagissent avec et sont affectés par la culture organisationnelle et les systèmes internes de redevabilité, à savoir la redevabilité des prestataires de soins et des gestionnaires envers leurs supérieurs hiérarchiques, le système bureaucratique et à d'autres bailleurs de fonds. Je suis intéressé par l'utilisation de des méthodes de recherche traditionnelles et moins traditionnelles, comme je l'ai mentionné ci-dessus, pour explorer ces questions. Certaines de ces réflexions et idées sont reprises dans un travail sur la gouvernance co-dirigé avec le professeur Lucy Gilson et financée par DFiD dans le cadre d'un consortium de recherche (RESYST).

As part of our series on the Bamako Initiative, Jean-Benoît Falisse interviewed Sassy Molyneux (Oxford University) who is working with the KEMRI-WT programme in Kilifi, Kenya. She has extensive experience on community accountability and participation research in East Africa and recently co-authored a literature review on the topic (community accountability at peripheral health facilities: a review of the empirical literature and development of a conceptual framework).

Jean-Benoît Falisse. What sparked off your interest in community accountability in health? Could you tell me a bit more about the KEMRI-WT research activities on this issue?

Sassy Molyneux. I’ve been interested in the interactions between communities and health systems for years, beginning with initial PhD research in the Coast of Kenya in the late 1990s.  Community participation and empowerment has long been emphasised as an important approach to ensuring affordable, locally responsive, health prevention and treatment services.  However achieving this is clearly far from straightforward.  An approach to involving communities that had been promoted in Kenya as in many other countries was the Bamako initiative, which in Kenya included the establishment of community run pharmacies, but unfortunately these pharmacies were struggling by the time of my PhD fieldwork.  There have also been many efforts over the years to promote community participation in health care in Kenya through village and facility level committees.  These committees were being discussed at the time of my PhD by health managers as a huge success, as ‘gold standards’ but it appeared that when user fees were reduced in Kenya in the early 2000s, their role was weakened through having less resources over which they had a say.  I could see then that there was great potential but also challenges in selecting and working with ‘representatives’ of such complex communities in very hierarchically organised health systems.

I increasingly began to hear about ‘community accountability’ which was and is being promoted for a whole range of instrumental and intrinsic purposes.  I was intrigued as to what ‘it’ really was, and if and how it differs from community participation.  I was also interested in learning more about how to feasibly involve communities given the difficulty in defining them, the technical nature of many aspects of health service delivery, and the complex power relations within communities and health systems, and between health providers and community members.  Working in a large multi-disciplinary research programme, I was also interested in learning from theoretical and practical insights and ideas from health system community accountability, to inform community involvement in the programme’s biomedical research activities.

Today most authors and public health practitioners talk about community ‘accountability’ rather than community ‘participation’ (as people did at the time of the Bamako Initiative). Is it really a different concept?

My understanding is that in community accountability, individuals or their representatives influence elements of health systems through voicing views and opinions, which are then responded to; therefore there is an element of answerability.  This requires action and response through challenges and systems that support this.  I think that community participation is a broader term, which might well include this too.  But both terms are used differently and in overlapping ways.  Perhaps most important, regardless of the term or across both terms, is to consider the depth of community involvement, or the levels of genuine empowerment, because many writers have argued that community involvement can range from simple information giving to communities at one end of the spectrum, through consultation, to community influence and control at the other end.  This is important in highlighting that setting up opportunities of interacting with community members does not necessarily lead to community influence and control.  Moreover, there is the potential for ‘manipulation’ or ‘tokenism’ in community involvement initiatives; for paying simple lip service to a fashionable idea.  It was my recognition of both the potential but also the challenges and even possibly perverse outcomes associated with community accountability that led me to be inquisitive about this area.

In a recent literature review (2012), you point out that there are actually not that many studies on the impact of community accountability mechanisms. What do you think is the reason? Do we know what actually works?

There is a slight caveat to that finding in that we were focusing very specifically on accountability mechanisms linked to peripheral health facilities.  So there will be a body (probably several bodies) of literature that we did not consider that deal with community accountability without specific mechanisms linked to facilities.  Also there is likely to be research that has been conducted that’s not written up formally in reports that are (easily) publically accessible.

Part of the gap is I think related to accountability strengthening initiatives often being part of quite complex interventions being conducted in complex health and social systems.  When this is combined with the difficulties in defining and measuring many aspects of community accountability (for example depth of involvement or engagement, levels of empowerment, and subtle shifts in power relationships), designing and conducting convincing and relevant evaluation strategies becomes very challenging.  There is therefore a need for more innovative methodological approaches; of moving far beyond the simple RCTs or relatively standard qualitative methodologies.  This is a challenge that’s recognised in health systems research more broadly, with growing promotion for example of (participatory) action research, and interest in incorporating reflexive and deliberative approaches into evaluations to ensure that the tacit knowledge of the range of actors involved is adequately drawn upon.

You also point out that most of the literature has focused on health facility committees. Why is it so? What are the other existing mechanisms? Any you think is particularly promising?

As I mentioned above, we were focusing very specifically on accountability mechanisms linked to peripheral health facilities so that might in part explain this.  Of course there are many other forms of community groups that advocate for health improvement, that are not specifically linked to facilities, including those that have been more spontaneously initiated and established by community members themselves.  And at facilities there are other interventions such as patients’ rights charters (to promote awareness of rights and interest in demanding change) and information sharing and suggestion boxes (to reduce information asymmetries and encourage ideas and opinions to be voiced), and other mechanisms which can be loosely termed community monitoring.  The latter often involve community members and health providers deciding together on priority areas for action/change, implementation of change, community monitoring of progress, and information sharing with the public about health facility progress along the lines of the indicators learned.  These are potentially very exciting initiatives, and the challenge then becomes sharing the lessons across different contexts and levels of the health system, and encouraging spread and adaption of successful initiatives to other places.

About external validity. What can we learn from necessarily local experiences of community accountability? How strong are the contextual and cultural factors in explaining the success of mechanisms of community accountability?

I think we saw from our review that while although of course community accountability initiatives have to be locally appropriate and responsive, there are cross cutting ideas that emerge that are relevant across all sites; a form of theoretical generalizability that is helpful for initiatives in other settings.  So for example in our work the importance of: clarity in community members’ roles and responsibilities; and information availability and access.  Also the need to carefully consider remuneration and other forms of incentives for community representatives, the challenges of asymmetries between health staff and community representatives in resources and power, and the importance of building trustful relationships.  Many of these aspects are in turn linked to how much real interest and value there is from the health system in community inputs.

You advocate for mixed-methods research on community accountability mechanisms. Could you explain how the qualitative and quantitative approaches reinforce/complement each other when exploring questions of community accountability? Would a single method necessary be incomplete or weaker?

I think good quality qualitative approaches can be in themselves appropriate for exploring the complexities I’ve described above.  A challenge is to be given enough space in write ups and particularly in peer- reviewed journals to convince readers of the methodological and analytical depth of studies.  Some qualitative studies appear to be relatively superficial group discussions and individual interviews through which it is very hard to give justice to the topic.  To complement these approaches with quantitative methodologies – where possible and relevant to the specific question – can assist to give an overall picture of scale of issues/impacts, and can be helpful also in research uptake; in framing the importance of initiatives to particular audiences.  As noted above, incorporating more ‘novel’ approaches into qualitative or mixed method evaluations – for example participatory approaches, deliberative activities and key actor reflections could strengthen studies further.   Here, I think there is a need to continue to share ideas about how to strengthen the trustworthiness and transferability of the data gathered through such methodological approaches, and to convince others of this quality in order to inform policy and practice.  There are numerous community accountability initiatives being implemented all of the time – either initiated and sustained by communities or representatives themselves, or by governments and other actors.  Finding new ways to document and evaluate such activities convincingly to key audiences would be helpful.  This would require unpacking not only of the successes but also of the challenges and failures, and the reasons behind the outcomes.

It seems there is a recent renewal of research on community participation/accountability. Would you agree? What do you think are the main remaining areas of research on community accountability (in health)?

I think community participation/accountability is (re)emerging as an area of focus and attention in policy and practice and therefore in research also. This is possibly assisted by the new terminology!  My area of interest now, building on from past research, is how forms of external or community accountability such as committees and community monitoring, interact with and are affected by organisational culture and internal accountability systems ie answerability of health providers and managers to their bosses up the bureaucratic system and to other funders.  And I’m interested in drawing on both traditional and less traditional methodological approaches, as I’ve mentioned above, to doing this.  Some of these thoughts and ideas are being taken up through governance work co-led with Professor Lucy Gilson, and funded by DFID as part of a research consortium (RESYST).

Jean-Benoît Falisse

For the second interview of our series on the Bamako Initiative, Jean-Benoît Falisse interviews Zan Yaya Konaré. He is the President of Mali's FENASCOM. FENASCOM is the federation of the community associations (ASACO) that have been managing Mali community health centres for more than two decades. This experience is often seen as one of the most advanced examples of community participation as communities are the legal and actual owners of the community health centres.


JBF - Mali is often mentioned for its ASACO, could you tell us when and how it all started? How does it fit into the Bamako Initiative (BI)?

ZYK - Community health initiatives emerged in 1990 under the joint influence of an engaged civil society and  a new Health and Population sectorial policy. They responded to both a growing demand for health care and limited resources of the State. The health policy of that time favoured the emergence of community health associations ('Association de Santé Communautaire' - ASACO in French). It also allowed the State to devolve primary health care services to communities of users. This is done through a mutual assistance agreement which defines the obligations of each party. Community health centres are public facilities that follow national-level regulations.

The principles for creating and running community health centres ('Centre de Santé Communautaire', CSCOM) are cost recovery and community participation in the financing and management of health care. The experience lasts since 1989. Several funding mechanisms support the community health system: sectorial budget support, transfer of skills and resources from the state to local health authorities, recovery of the costs of services and the existence of a National Agency for local government investments. In addition to these CSCOM funding mechanisms, a system of mutual health insurance organisations improves the affordability of health care for the poor.

ASACOs recruit part of their staff and the Ministry of Health appoints the rest (especially in areas where CSCOM are 'unsustainable'). Yet, as the creation of new community health centres increases the health care coverage, the supply and quality of the minimum package of essential health services remains sometimes insufficient. This is mainly caused by deficiencies in community health centres’ staffing and health agents’ motivation and qualifications in poor areas (categories 1 and 2, the poorest areas).

Was there any initiative of community participation before the ASACO? Is there a tradition of democratic participation at the village level in Mali?

In Mali, the only existing community initiative before the BI was a Primary Health Care (PHC) programme which was based on traditional birth attendants and midwives paid out of the funds of the Regional and Local Development taxation. This experience had not been conclusive as taxes that were supposed to fund the wages of these health workers were often unpaid. Community health workers did not receive their salaries on a regular basis and abandoned their job or got paid directly, at the expense of the very existence of the health centre.

What has been the public support for the ASACO system? What was the motivation for setting up such a system?

In order to improve the health of the general population and of mother and child in particular, our strategy is to expand access to health services. We use a process of planning, organisation and decentralised management that follows a community-based approach (which implies environmental studies, community rehabilitation, etc.). In this approach, which seeks to set up a network of local structures, systematic and standardised implementation is dismissed in favour of implementation by the “cercles” (local authorities) and communities who are the implementing partners. To benefit from state funding and other external support, the communities that want to create a community health centre must meet a number of criteria including: respect of the national standards, existence of a development plan, financial and / or physical contribution of the community to at least 50% of the budget of the health centre, commitment of the Local Development Committee of the “Cercle” (1) to health at least 7% of the revenue generated by the local development tax local, support of the Regional Directorate of Health and Social Affairs and organisation of a sustained campaign of information and sensitisation of the population in order to obtain the participation of government and organised communities.

We also seek to improve quality through a shared technical framework and increase the viability of the health system at the “Cercle” level through the rational and efficient use of resources (personnel, drugs, finances, assets) and the organisation of community participation.

FENASCOM has a network of more than 30,000 volunteers who animate the community health movement in Mali. Volunteering is part of the tradition in Mali and our culture highlights the importance of solidarity.

Are all the health centres in Mali managed the same way? What is the strength of the ASACO health centres?

All health centres are not managed in the same way. The health-care structure of Mali has three levels:

1. The community health centre (CSCOM) is the first level health centre. It is the first contact point for the patients. It belongs to the community, which is organised in a Community Health Association (ASACO). The CSCOM is created and managed by the ASACO which represents the population in the management. The administration is provided by a Management Committee designated within a board elected by a general assembly of the population.

2. The reference health centre (CSREF) is the second level health centre. It is created by the state and is co-managed by the national government, the local government and the community. The state builds up the centre and installs the necessary equipment and staff. The mission of the CSREF is essentially to support community health centres within the referral / evacuation system. The local government recruits senior staff and oversees the management and decision-making process. The community helps in the functioning, in particular through the implementation of the referral and evacuation system and participation in the management and decision process. The centre uses its own funds to support staffing and operating costs. A board and a management committee are established under the responsibility of the local authority. The technical and administrative direction is provided by the surgeon/chief-doctor who is also a member of the Management Committee.

3. Hospitals are the last resort for patients, especially for specialised interventions. They are managed like an enterprise, with a board of directors and senior management.

The ASACOs' strength is that they are the emanation of the people and they are autonomous from the central government. They are the legitimate representatives of the people in the implementation of the health policy of the government.

What were the main developments of the ASACO system in recent years?

The figures speak out for themselves. There were 44 ASACO in 1994 when the FENASCOM was created. They are now 1,060, with as many existing functional CSCOM. The health coverage has increased from 29% in 1992 to 80% in 2012. The FENASCOM has also contributed to the reduction of unemployment among graduates as is the second largest employer after the state in the field of health care, with 52% of the staff in charge.

There are also less quantifiable achievements such as a better connection between health services (CSCOM) and populations and a better control of the cost of health care as the profit margins of the health centres are determined by the communities themselves, based on their income.

 What are the main challenges today? How to overcome them?

To ensure efficient and effective support in the implementation of the state health policy, FENASCOM must face certain challenges which include: to medicalize (i.e. staff with a doctor) all CSCOM; to fight the illegal sale of drugs; to contribute to te reduction of maternal and infant mortality by extending the strategy of critical care in the community; to ensure good governance within the community health 'family'; to ensure an active and responsible participation of women and youth in decision-making processes; to provide efficient answers to the problem of sustainable management personnel at community health centres; to contribute to the extension of universal coverage in health, including through compulsory health insurance and volunteering programmes for young people.

You are the head of the FENASCOM, which brings together community health organisations. Could explain the purpose and functioning of your federation?

FENASCOM was created in 1994 by the ASACOs. Its aim is to ensure the necessary conditions for sustainable development and achievement of the government’s health commitments to the population. It has been registered as a non-profit organisation since 2002 and received technical and financial support from the State and its partners. FENASCOM includes 1,060 ASACO members and five mutual health insurance organisations. FENASCOM collaborates with other organisations of the civil society working in the field of health through a consultative framework that has been developed at the national level.

FENASCOM actively participates in various bodies of the health system in Mali and in various meetings related to community health. The objective of FENASCOM is households’ access to quality health services in line with their needs and in accordance with established standards. This includes the participation of ASACOs that are competent, dynamic and able enough to provide answers to the health problems of population.

FENASCOM is open to any Community Health Association and/or Mutual Health Insurance Organisations officially recognised by the competent authorities. FENASCOM is organised into 59 local federations, 9 regional federations and a national federation. A national congress meets every five years and a coordination council every two years. Daily management is handled by the executive offices at different levels. A Permanent Secretariat is responsible for the daily management of the FENASCOM at the national level.

At the moment, Mali does not appear in the headlines for its ASACO but rather for the war that ravages the north of the country. Do you know what happened to the ASACOs located in the northern part of the country? What is the political dimension of the ASACOs?

In the wake of the recent rebellion (January, 17, 2012), FENASCOM immediately organised a consortium to deal with the current situation of community health in the strip occupied by the rebels. This initiative has been strengthened with the events of the coup of the 22nd of March 2012. The goal is to gather information and propose actions. An emergency response plan has been developed; here is an excerpt that relates the situation on the field:

“Information to be confirmed indicates the devastation or destruction of socio-health infrastructures at different degrees in the three 3 northern parts of the country. [...] The health situation is worrying as services have stopped in several community health centres and hospitals in the northern regions. This is exacerbated by the departure of the majority of the socio-sanitary staff out of the areas affected by this crisis”.

Interestingly, it was reported in Gao [occupied by the rebels] the creation of a "monitoring commission of the situation" composed of religious leaders, Imams, customary chiefs, heads of districts and community leaders. It is responsible for the assessment of the crisis and negotiation with the armed rebels whenever necessary, especially in regard to various health abuses including sexual violence.


Note:
(1) the "Cercle" is the local administrative level in Mali.

Jean-Benoît Falisse

Nous commençons notre série d'interviews par la professeur Susan Rifkin (London School of Economics et London School of Hygiene & Tropical Medicine). Susan Rifkin a commencé à étudier la problématique de la participation communautaire il y a plus de quarante ans. Elle a une longue expérience de terrain en Asie et en Afrique. Elle nous parle de la recherche passée et future sur la participation communautaire et du futur de la participation communautaire en général. La participation de la communauté, nous dit-elle, ne peut se limiter à une intervention et le prochain grand défi de la recherche sera de comprendre les processus qui lient participation communautaire et santé de la population.

Jean-Benoît Falisse: Vous avez travaillé sur la participation communautaire dans la santé depuis beaucoup années maintenant. Qu'est ce qui a déclenché votre intérêt pour le sujet? Comment avez-vous commencé?

Susan Rifkin: Quand j'ai fini ma maîtrise en études chinoises à l'Université de Columbia à New-York, je suis allé à Washington DC pour travailler à la National Academy of Sciences (Académie Nationale des Sciences) comme secrétaire d'un comité dont l'objectif était d'ouvrir la communication avec la République Populaire de Chine. A l'époque (1968), les Chinois ne parlaient à personne, c'était la Révolution Culturelle. Cependant, les Américains étaient «impressionnés» par le travail des Chinois en santé publique. Ce n'était pas un sujet à controverse, alors j'ai rassemblé des informations et j'ai créé un bulletin d'information à propos de qui se passait au niveau de la santé publique en Chine. La principale chose qui a attiré mon intérêt a été l'implication des communautés locales. J'étais très intéressée par la façon dont les gens au niveau local, en particulier dans les zones rurales, étaient en mesure de s'impliquer et de prendre des décisions qui affectaient leur vie quotidienne. C'est donc l'expérience chinoise, et surtout les « médecins aux pieds nus », qui a suscité mon intérêt.

L'Initiative de Bamako vient en 1987. Est-ce que la date est importante? Quel est le contexte de la santé publique et des politiques de santé à ce moment? En dehors de la diffusion des idées de la participation communautaire à l'ensemble du continent africain, est-ce que l'Initiative de Bamako a apporté quelque chose de nouveau ou de différent par rapport aux précédents projets et politiques?

Je ne suis pas sûr que la date était si critique. Dans mon esprit, ce qui était critique à propos de l'Initiative de Bamako a été la direction que les soins de santé primaires ont pris. Comme vous le savez, l'UNICEF et l'OMS avaient organisé une conférence d'Alma-Ata et soutenu les soins de santé primaires depuis 1978. Pourtant, les soins de santé primaires ont surtout été pilotés par l'OMS dans les premières années et l'OMS ne pouvait travailler qu'avec les ministères de la santé à l'échelon local, ce qui signifie que les soins de santé primaires sont devenus un service de santé très médicalisé. Avec Bamako et l'UNICEF, les soins de santé primaires ont été déplacés vers les mouvements de développement communautaire, parce que l'UNICEF pouvait travailler avec d'autres ministères et partenaires, et l'a fait (avec le développement communautaire, l'eau et l'assainissement, l'éducation, etc.). Avec Bamako, la participation est devenue plus large et a commencé à se concentrer sur ce que les gens locaux pouvaient faire en termes non seulement de recevoir des soins médicaux, mais aussi d'activités génératrices de revenu plus diversifiées. Je pense que l'importance de Bamako, c'est l'approfondissement de ce qui était l'inspiration, la vision des soins de santé primaires pas uniquement comme des soins de santé, mais bien comme une vision plus large des déterminants sociaux de la santé. Un monde plus vaste s'est ouvert pour les communautés qui, pour la plupart, n'avaient jamais été concentrées sur la santé à moins d'être malades.

Quelle est votre opinion sur l'évolution des stratégies de participation communautaire en matière de santé au cours des 25 dernières années? Qu'est-ce qui a changé? Est-ce que les nouveaux concepts / stratégies de «redevabilité» ou de «gouvernance» communautaires sont vraiment différents des anciennes idées de la «participation» communautaire?

Je pense que ce qui a changé, c'est la reconnaissance du fait que la participation des communautés dans la santé c'est plus que les agents de santé communautaire. Les idées et les concepts de redevabilité et de gouvernance sont essentiels et doivent beaucoup à tout le mouvement de la « santé et des Droits de l'Homme ». Ce qui est sorti de tout cela est une grande implication de la société civile, notamment à travers des organisations telles que le mouvement populaire pour la santé auquel j'ai participé en tant que premier coordonnateur de l'Asian Community Health Action Network, le précurseur du mouvement populaire pour la santé. Je pense que mettre la santé et les Droits de l'Homme à l'ordre du jour a élargi la perspective de ce que la participation communautaire est et de quels sont ses défis. Cela a attiré l'attention des gens sur ce que sont les implications plus larges de la participation communautaire au-delà du cadre des services de santé.

Pensez-vous que le débat sur la participation de la communauté comme un « moyen » versus la participation comme une «fin» en soi soit toujours d'actualité?

Non, je pense que ce n'est plus pertinent aujourd'hui. Nous avons quitté ces points de vue  mutuellement exclusifs de la participation communautaire. Le "UK Medical Research Council" parle maintenant d'« interventions complexes »» et, comme la plupart des organisations actives sur la santé communautaire, reconnaît qu'il n'y a pas une façon unique de voir la participation. Toute la question des moyens et des fins a été dépassée par des expériences et par plus de recherche et de conceptualisation.

Quel est l'avenir de la participation communautaire dans la santé? Pouvez-vous vous parler d'expériences passées ou actuelles que vous jugez très prometteuses?

Je pense qu'il y a une reconnaissance croissante par les décideurs politique que la participation communautaire est essentielle et nécessaire mais non suffisante pour l'amélioration de la santé des populations. L'expérience des médecins chinois a montré que nous pouvions réduire radicalement les maladies transmissibles. Cela a été confirmé par mon travail à l'Académie Nationale de Sciences. Aujourd'hui, nous voyons un exemple d'implication communautaire axée sur la prévention dans le Obamacare aux États-Unis. Pour la première fois aux Etats-Unis, le gouvernement finance des groupes de santé communautaire avec l'espoir de promouvoir la prévention et d'impliquer les communautés dans leur propre santé. Lorsque les communautés prennent conscience de leurs droits et de leurs obligations, elles sont dans une bien meilleure position pour négocier des politiques et la prestation de services avec les décideurs politiques. Je pense aussi que, observant la hausse des coûts des soins de santé, les décideurs politiques voient que la participation des personnes qui prennent soin de leur propre santé en tant que communautés et en tant qu'individus réduit le fardeau sur les services de santé. Par exemple, la réduction de l'obésité et des maladies cardio-vasculaires exige un engagement personnel. Je pense donc que la participation communautaire et le soutien communautaire sont devenus cruciaux.

Je reviens d'Australie, où j'ai passé deux semaines dans diverses institutions et conférences ; l'une avec le Réseau International Rural  (International Rural Network) était particulièrement intéressante. J'y ai entendu parler de l'expérience des conseils communautaires aborigènes. Il y a maintenant plusieurs conseils communautaires aborigènes qui offrent des soins de santé pour leur propre communauté, sans même une supervision du gouvernement. S'appuyer sur les expériences de ces communautés non seulement pour augmenter l'appropriation des services de santé par la population mais aussi pour transmettre des messages de santé pertinents dans leur contexte est important. Un autre exemple est bien sûr l'Inde et la mission santé en milieu rural (rural health mission), qui s'est engagé à impliquer les communautés locales dans leur programme « d'Activiste de Santé Sociale Accrédité » (ASHA - Accredited Social Health Activitist), qui est leur programme pour les travailleurs de santé communautaire. Le comité villageois d'hygiène et assainissement supervise l'ASHA et la santé en général et prend ses responsabilités concernant les services de santé et leur évolution. Je pense que tout cela constitue des progrès au niveau de la santé communautaire et de la participation communautaire.

Vous avez travaillé sur l'évaluation de la participation communautaire pendant une partie importante de votre carrière. Dans un article récent (2010), vous présentez une révision de votre cadre d'analyse séminal de 1988 et de son graphe en toile d’araignée à 5 dimensions (le « spidergramme »). Quels sont les principaux changements et ce qui a changé dans l'évaluation de la participation communautaire depuis 1988?

Lorsque nous avons commencé avec le spidergramme, nous avons conceptualisé un continuum de ces cinq facteurs qui présentait une participation large à une extrémité et étroite à l'autre. Les cinq facteurs étaient liés dans la visualisation de l'organisation d'un programme de participation. Ce que nous avons appris depuis 1988 est que «étroit» et «large» sont des termes très vagues. Beaucoup de travail a été fait et dans l'article 2010, nous avons examiné la façon dont les communautés sont impliquées, en particulier le long des lignes de l'autonomisation. Nous parlons de participation habilitante (empowerment) pour parler de la possibilité pour des personnes sans pouvoir d'acquérir des compétences, des connaissances et de la confiance pour prendre des décisions concernant leur propre vie.
Ceci est crucial pour le dialogue sur la participation de la communauté en matière de santé. Selon cette définition, la participation habilitante (empowerment) ne peut jamais être donnée: elle est toujours prise. De nombreux programmes, dans la santé en particulier, considèrent comme l'un de leur objectif de «responsabiliser» les communautés et je pense que c'est une mauvaise compréhension du concept. En révisant le « spidergramme » pour regarder la mobilisation d'un côté et de l'autonomisation de l'autre, nous avons un outil qui nous permet de dire si la participation est contrôlée par ceux qui sont les décideurs politiques et les gestionnaires et qui ont décidé de ce que les gens doivent faire ou bien si les communautés font des choix pour elles-mêmes. C'est l'exemple du conseil de santé communautaire des australiens aborigènes, où les gens décident ce qu'ils veulent et de s'approprient le programme. Il s'agit de la nouvelle vision qui est encapsulée dans notre article de 2010.

Récemment, des approches plus quantitatives ont été utilisées pour évaluer l'impact de la participation de la communauté (par exemple, Björkman et Svensson 2009). Que pensez-vous d'eux? Sont-elles compatibles avec les méthodes qualitatives / mixtes habituellement utilisées dans la recherche sur la participation communautaire?

Je pense que le papier de Björkman et Svensson est important. Dans un sens, je suis heureuse avec cet article parce qu'ils se penchent sur la notion de processus. En ce moment, la plupart de la recherche voit la participation communautaire comme une intervention et donc utilise un paradigme scientifique inspiré des sciences naturelles pour regarder linéairement un effet causal. Cette approche inductive est très étroite; des causes directes ont des effets. C'est le cadre de l'article de Björkman et Svensson. Je suis en train de procéder à un examen systématique de la littérature sur la participation communautaire dans la santé et la plupart des articles que je trouve continuent à considérer la participation communautaire comme une intervention. Ils sont à la recherche du Saint Graal, qui est le lien entre la participation et l'amélioration de l'état de santé. Ce que nous constatons, c'est que la plupart des recherches essayent de reproduire le paradigme dominant dans le domaine médical, les essais avec cas-témoins aléatoires (randomised control trial RCT). Elles prennent ce paradigme comme l'étalon-or mais le lien entre la participation et une meilleure santé reste jusqu'ici à prouver. Cette approche ne donne pas une attention suffisante au processus, le reléguant souvent à une "variable confondante" dans le cadre d’un essai randomisé contrôlé.

Ce que nous devons examiner de plus près est le processus. Björkman et Svensson le font mais leur enquête sur le processus est, de leur propre aveu, insuffisante. Ce qu'ils disent est que le monitoring communautaire conduit à de meilleurs résultats sanitaires. Ils disent que la raison est que la communauté tient le fournisseur de services de santé responsable, mais on ne sait pas comment ils font. Pourquoi le prestataire de services de santé répond-il à la communauté? Est-ce que ces personnes le paient? Quelle est la motivation? Ce n'est sûrement pas de l'altruisme (je connais un peu le contexte, j'ai travaillé en Ouganda et ai vécu et travaillé au Kenya). Il reste encore de nombreuses boîtes noires qui empêchent de voir les choses clairement.

L'autre question à propos de la recherche dans ce domaine est de savoir comment aborder les questions de pouvoir et de contrôle, clé de la prise en charge communautaire des programmes de santé. Björkman et Svensson, par exemple, ne tiennent pas compte de l'autonomisation. Où doit venir l'autonomisation et la contribution de la communauté venir dans l'équation globale de la recherche? Trickett (2011) qui est un psychologue social aux États-Unis et se penche sur l'évaluation participation de la communauté, dit que l'examen de la participation communautaire à l'aide de ce cadre d'intervention [la RCT] relègue les connaissances locales au rang de l'influence d'une science mis au point par d'autres. Je travaille avec un groupe de personnes sur un cadre alternatif pour mieux comprendre ce phénomène et englober l'idée de processus. Le vrai défi est de savoir comment en faire un cadre valable et acceptée analytiquement pour comprendre le potentiel et les défis de la participation de la communauté dans l'amélioration des résultats de santé.

Peut-on vraiment comparer les expériences de participation communautaire en matière de santé? Que pouvons-nous apprendre de différents cas?

Je pense que nous avons juste besoin de sortir de ce cadre qui est linéaire et causal. Ce que nous pouvons faire est de généraliser des domaines qui sont importants pour la participation. Si je regarde les études de cas et des revues systématiques, je peux identifier au moins trois domaines généralisables qui façonnent la relation entre la participation communautaire et la santé. Ceux-ci sont le leadership, la gestion et l'allocation des ressources et la mobilisation. Il en existe d'autres, et nous cherchons à les identifier dans la revue de littérature systématique que nous essayons de faire. Si vous avez des domaines généraux, vous pouvez voir comment, à l'intérieur de ces domaines, observer des résultats dans des situations spécifiques. Avec un tel cadre d'analyse vous pouvez avoir une meilleure vue sur le processus de développement communautaire et une meilleure idée de quoi attendre.

By Jean-Benoît Falisse

Susan Rifkin (London School of Economics and London School of Hygiene & Tropical Medicine) has accepted to be the first interviewee of our series. Professor Rifkin is one of the most knowledgeable researchers on community participation in health, a topic she started to study more than forty years ago. She has extensive field experience with international and non-governmental organisations in Asia and Africa and has taught at various universities across the globe. With her unique perspective and experience, she tells us about the past and future of community participation and community participation research. Community participation, she argues, cannot be limited to an intervention; the next big challenge of research will be to understand the processes that tie community participation and health outcomes.

Jean-Benoît Falisse: You have been working on community participation in health for quite a few years now. What sparked off your interest in the topic? How did you start?

Susan Rifkin: When I finished my masters in Chinese Studies at Columbia University, I went to Washington DC to work at the National Academy of Sciences, as Secretary to a committee whose objective was to open communication with the People's Republic of China. At the time (1968), the Chinese were not talking to anyone; it was the Cultural Revolution. However, the Americans were “impressed” with the Chinese work in public health. It was not an area of contention and I put together information and created a newsletter about was going on in public health in China. The main thing that got my interest was the involvement of local communities. I got very interested in how people at the local level, especially in the rural areas, were able to get involved and take decisions that affected their daily lives. So it was the Chinese experience, and especially looking at the barefoot doctors, that sparked of my interest.

The Bamako Initiative comes in 1987. Is the date important? What is the public health / health policy context at that moment? Apart from spreading ideas of community participation to the whole African continent, was the Bamako Initiative bringing something new or different from previous projects and policies?

I am not sure the date was so critical. In my mind what was critical about the Bamako initiative was the direction Primary Health Care took. As you know, UNICEF and WHO sponsored a conference in Alma Ata and had supported Primary Health Care since 1978. Yet, PHC was spearheaded by WHO in the first years and WHO only could work with Ministries of Health at the local level, which means PHC became very much a health service-, medical-oriented movement. With Bamako and UNICEF, PHC moved into a more community development movement; because UNICEF could work with other ministries and partners and did so (with community development, water and sanitation education, etc.). With Bamako, participation became wider and began to focus on what local people could do in terms of not only getting medical care but also broader income generating activities. I think the importance of Bamako is that it widened what was the inspiration, the vision of primary health care not just as health care but the broader view of social determinants of health and a wider world for communities which, for the most part, were never focused on health unless they were sick.

What is your opinion about the evolution of strategies of community participation in health in the last 25 years? What has changed? Are newer concepts/strategies of community 'accountability' or community 'governance' really different from older ideas of community 'participation'?

I think what has changed is the recognition that community participation is more than community health workers. The ideas and concepts of accountability and governance are critical and this has been driven a lot by the whole movement of health and human rights. What is has come out of that is a lot of civil society involvement, particularly through organisations such as the people's health movement (PHM), which I was involved in as the first coordinator of the Asian Community Health Action Network the forerunner of the PHM. I think putting health and human rights on the agenda has broadened the whole view of what community participation is and what its challenges are. It has made people more focused on what are the wider implications of community participation outside the health service framework.

Do you think the debate about community participation as a 'means' vs. an 'end' is still relevant?

No, I think this is irrelevant now. We have moved out of these mutually exclusive views of community participation. The UK medical research council now talks about “complex interventions” and, as most organisations in the health community, acknowledge that there is not just a single way of looking at participation. The whole question of means and ends has been bypassed by experiences and by more research and conceptual thinking.

What do you think is the future of community participation in health? Could you think about very promising past or present experiences?

I think there is a growing recognition by policy makers that community participation is critical and necessary but not sufficient for improvement of the health of the populations.

The Chinese doctors’ experience showed that we could radically reduce communicable diseases. That was confirmed by my work at the National Academy. Today we see that same example of community involvement focused on prevention in the Obamacare in the United States. For the first time in the Unites States, government is funding community health groups in terms of hoping to promote prevention and getting them involved in their own healthcare. As communities become aware of their rights and their obligations, they become in a much better position to negotiate policy and the provision of services with policy-makers. I also think that, as we see health care cost rise, policy-makers see that the involvement of people taking care of their own health as communities and as individuals reduces the burden on health services. For example, the reduction of obesity and cardio-vascular diseases demands a personal commitment. So I think community participation and community support has become crucial.

I just came from Australia where I have been two weeks at various institutions and conferences; one was with the International Rural Network which was quite interesting. I learned about the Aboriginal community councils’ experience. There are now several Aboriginal community councils that are providing health-care for their own people, not even with government supervision. Drawing from the experiences of those communities to not only increase ownership but also make health care messages relevant in their context is important. Another example is of course India and the rural health mission which is committed to involving local communities in their ASHA (Accredited Social Health Activist) programme, which is their community health worker programme. The village water and sanitation committee oversees the ASHA and health and takes responsibilities for how health services progress. I think these are all advances in community health and community participation.

You have been working on the evaluation of community participation for a substantial part of your career. In a recent article, you present a revision of your 1988 seminal framework and its 5-dimensions “spidergramme”. What are the main changes and what has changed in the evaluation of community participation since 1988?

When we started out with the spidergramme, we looked at a continuum of these five factors which saw participation wide at one end and narrow at the other. The five factors were tied together in the visualisation of the organisation of a participation programme. What we have learned since 1988 is that “narrow” and “wide” were very vague. Lots of work has been done and in the 2010 article we looked at how communities are involved, particularly along the lines of empowerment. We talk about empowerment as providing opportunities for people without power to gain skills, knowledge and confidence to make decisions about their own lives.

This has been critical in terms of the dialogue on community participation in health. By this definition, empowerment can never be given, it always is taken. Many programmes, health programmes in particular, see as one of their objective as to “empower” communities and I think this is a misunderstanding of the concept. By revising the spidergramme to look more at mobilisation at one end and empowerment at the other, we had a vision of whether participation is being controlled by those who are the policy-makers and managers and have decided what people should do and get or people make choices for themselves. This is the example of the community health council of the Aboriginal Australians where people decide what they want and take ownership of the programme. This is the new vision that is encapsulated in the 2010 article.

Recently, more quantitative approaches have been used to assess the impact of community participation (for instance, Björkman & Svensson 2009). What do you think about them? Are they compatible with the qualitative/mixed-methods usually used in research on community participation?

I think the Björkman and Svensson’s is important. In a sense, I am pleased with that article because they do investigate the notion of process. At this moment most research views  community participation as an intervention and therefore uses a natural scientific paradigm to look at it linearly as a causal effect. This approach is inductive and very narrow; direct causes have effects. This is the framework of this article. I am currently conducting a systematic literature review of community participation in health and most of the articles I find continue to look at community participation as an intervention. They are seeking the Holy Grail, which is the link between participation and improved health status. What we are finding is that most research is trying to duplicate the dominant paradigm in the medical field, the random case control trials (RCT).  It takes this as the gold standard but the link between participation and better health has so far proven delusive. This approach does not give adequate attention to process often relegating it to a “confounding variable” in the framework of RCT.

What we need to look more at is process. Björkman and Svensson do that but their investigation of the process, to their own admission, is inadequate. What they say is community monitoring leads to better health outcomes. They say the reason is because the community holds the health service provider responsible but it is not clear how they do that. Why would the health service provider respond to the group of community people? Are the people paying them? What is the incentive? It surely is not because of altruism (I know the context a bit as I worked in Uganda and lived and worked in Kenya). There are still these black boxes that do not help make things very clear.

The other question about the research in this area is how we address issues around power and control, key to community ownership of health programmes. Björkman and Svensson, for instance, do not take account of empowerment. Where do empowerment and community understanding and contribution come in the whole equation of the research? Trickett (2011) who is a social psychologist in the United States and looks into community participation assessment, says that looking at community participation using this intervention framework relegates local knowledge and influence to science devised by others. I am working with a group of people on an alternative framework to understand this better and encompass the idea of process. The real challenge is how to turn this into a valid and accepted analytical framework to understand the potential and challenges  of community participation in improving health outcomes.

Can we really compare experiences of community participation in health? What can we learn from different cases?

I think we just need to get out of that framework that is linear and causal. What we can do is to generalise domains that are important for participation. If I look at case studies and systematic reviews, I can identify at least three generalizable domains which shape the relationship between community participation and health. These are leadership, management, and resources allocation and mobilisation. There are others, and we are looking at them in the systemic review we are trying to do. If you have generalised domains you can look at how these domains define outcomes in specific situations.  With such a framework for analysis you can have a more valid view about the process of community development and a better ground for defining expectations.

Jean-Benoît Falisse

For the 25th anniversary of the Bamako Initiative and the Harare Declaration, we asked the historian and economist Jean-Benoît Falisse to conduct a series of interviews about community participation. In this first article, he introduces the topic.

Twenty-five years ago, the African Ministers of Health invited by UNICEF and WHO in Bamako, Mali, declared their willingness to improve access to essential medicines and health services. At the core of the Bamako Initiative (BI) is the belief that the participation of users in the management (and sometimes delivery) of health services can accelerate the achievement of primary health care, which is a concept that was formalized twelve years earlier at the Alma-Ata Conference (1978). The context of the Bamako Initiative is not unlike the one that prevails today in Southern Europe: states faced a serious economic setback (at the time the oil peak leading to the debt crisis) and fiscal austerity measures were imposed upon them by international institutions like the International Monetary Fund and the World Bank.

Twenty-five years after Bamako, "health for all" unfortunately remains at best a long-term ambition. Despite some local successes, community participation in health was not the magic bullet some had hoped for. This leads to a series of questions. To what extent did participatory initiatives in health bring changes? Are our expectations for community participation too high or is it, as an international civil servant told to me recently, that "we just did not really give a chance to community participation?”

In the coming months, I will share with you different contributions on the subject (1). I will try to understand the legacy of the BI and explain past, present and future strategies of community participation in health. As a preamble to the upcoming interviews, I will briefly introduce the BI, its historical context and some recent developments in the field. I have identified five key questions.

Question 1: What community participation?

At the heart of the BI is a threefold principle: (1) self-financing mechanisms at the peripheral and household levels, (2) encouragement of community mobilisation for health (community participation) and (3) improvement of drugs supply. Additional financing by communities has often been seen as the reason for increased community participation. The direct consequence of the community participation advocated by the BI has been the set-up of elected community committees in many African countries. These committees all have the ambition to make communities (co-)manage their health centres.

The idea follows 1970s’ and 1980s’ experiences and aims at providing a better interface between service providers (care staff) and patients. In the field, the role of (co-) administrator/manager granted to the community and its health committee is nevertheless conflated with another “weaker” and less empowering form of community participation: community health workers and other heirs of the "barefoot doctors" popularised by Maoist China policies. Often implemented by vertical programs, these health workers are an instrument to deliver services at the heart of communities, mostly on issues of disease control and prevention. In many national experiences, the distinction between the different forms of participation remains blurry. In particular, there is little distinction between community participation as a way to devolve services to community members and community participation as the community (co-)management of health centres. This confusion is in part reflecting two decades of debate on participation as either an end in itself or means for other purposes.

The 'content' of community participation is one of the questions we will explore in the forthcoming series of interviews. As I am writing this text from Bukavu in the Democratic Republic of Congo, where members of health committees are also community health workers (they are sensitisation and liaison officers as well as co-managers), I believe that the issue is relevant well beyond academic circles or ideological divide.

Question 2: What integration in the political context?

Before the BI, it was rather the non-aligned and socialist sympathisers’ countries that experimented community participation (Tanzania, Kenya, India, etc.). The BI must be seen as a follow-up of the Alma-Ata Declaration, which remains a surprising commitment of the countries of the world -including in the West- to a political philosophy marked by experiences of Chinese decentralised socialism (village communities managing their health) (2). However, the BI is also the child of the Washington Consensus, new public management, “good” governance and market paradigms. In fact, the BI ideas seem to have been endorsed by a wide spectrum of international development practitioners: from the legatees of the "1968 movement" to the supporters of the Reagan / Thatcher 1980s neo-liberal come-back, from grassroots NGOs to the World Bank.

In the years that followed the BI, the debate about the nature of community participation (empowerment or instrument) has certainly occurred in some (academic) circles but on the field, roughly the same type of "health committees" have been implemented across the African continent. Surprisingly, the political dimension of citizen participation in the management of basic social services (such as health care) has been little discussed (this is the issue of “power”). Since 1987, much water has flowed under the bridge: decentralisation but also democracy have spread throughout Africa. In our series of interviews, we will consider how community participation – sometimes presented as a technocratic proposal – occurs in the context of social, political and economic mobilisation at the local level. What part of the population is included in strategies of community participation? What are the links between community participation and local and national politics?

Question 3: New health policies, new forms of participation?

Although community participation has not exactly met all expectations of the participants of the conference in Bamako, it has also evolved in contact with new health policies. Some of these policies, pretty much as the BI was in its time, have generated high hopes for improving health and access to care.

For instance, performance-based financing strategies are questioning the role of the community as a stakeholder. Can it be contracted for delivering services to the population? Can it be used as a tool to perform verification tasks in the system? Should rather community be strengthened in its role as a co-manager, as proposed by the BI? Should it become a watchdog that ensures that performances and results meet the needs of the population? How to ensure that the voice of the people continues to be transmitted and heard when financial incentives drive the system?

Free health care on a large scale also poses new challenges. Although the BI was not limited to cost recovery, it has often been read as such. In the BI model, the money collected from households paying for care is used to develop services and promote access (sometimes via a waiver scheme) to essential treatments, including for vulnerable groups identified by the health committees. With the removal of user fees, the financial interest community members have in the health centre management disappears. Could it be that the motivation of the population to participate is affected?

Free care and performance-based financing are two of the most popular health policies currently being developed in Africa and this series of interviews will assess their implications for community participation in health.

Question 4: Accountability, a paradigm shift?

The 25 years that have passed since the BI also correspond to changes in the language of international health (nowadays people talk about “global” health). The mainstream rhetoric has put "community participation" a little bit aside as the popularity of terms such as "accountability" and "transparency" has been rising. These concepts combine readily with "community" or "social", and the question now becomes whether the spirit of community participation promoted by the BI remains within the "new" concepts of accountability, governance and transparency. A whole new generation of policies and strategies of "social accountability" in health but also in other basic social services are appearing (balanced score cards, social audit, etc.). Do these strategies imply the same kind of community involvement that the one advocated by the BI? Is “community accountability” an enhanced version of "community participation" or rather its bleak ersatz?

Question 5: What about the research?

Alongside these developments in health policies and strategies, research about community participation has also evolved in the last 25 years. In the last few years, new methodologies have developed. They propose a more quantitative approach, sometimes mixed with qualitative insights and contrast with ethnographic and sociological approaches that have been usually used for the study of community participation (pre- and post-Bamako). “What can we learn from these new research methods?” and “what is the state of research on the mechanisms of community participation?” will constitute a final theme of our series.

Bearing all these issues in mind, we will meet researchers and practitioners of community participation. Listening to their reactions and comments, we hope to better understand the heritage of the Bamako Initiative and the future of community participation in health.

Notes:
(1) This is the topic of my DPhil at the University of Oxford and the central idea of different interventions Cordaid is experimenting in the African Great Lakes with Cordaid, of which I hope to document the impact soon.
(2) In retrospect, we can assume that high-income countries were taking little risk when signing a text where low and middle-income countries entrust local communities to manage and finance their health care.