Jean-Benoît Falisse

We continue our exploration of community participation in Africa, 25 years after the Bamako Initiative. Dr. Frederick Golooba-Mutebi is a political scientist and Honorary Senior Research Fellow at the School of Environment and Development, University of Manchester and Research Associate of the Africa Power and Politics Programme at the Overseas Development Institute in London. He has widely published on health, local government and other topics, with a concentration on Uganda, Rwanda, South Sudan and South Africa.

Jean-Benoît Falisse: You have been working on issues of community participation for quite a few years now. What sparked off your interest for this topic?

Fred Golooba-Mutebi: My interest stemmed from the knowledge I had of how the society I was born in works. I had grown up in it and knew roughly how people felt and thought about different things. A key aspect of participation is that it presumes that communities, wherever they are found, always want to assert themselves over their leaders or people in positions of power and authority. My own society is very hierarchical in orientation. People generally treat leaders with deference. And even if one does not respect a leader or has an issue against him or her, they are more likely to avoid than confront them. The idea of participation with people holding their leaders to account is therefore a difficult proposition. Traditionally local leaders did not account directly to the community. They accounted to their superiors, the senior chiefs, and ultimately to the king. In distant (pre-colonial) times, before the region I was born in became more populated, people could easily move house from one area to another one. The possibility of shifting enabled them to vacate areas presided over by leaders they did not like to those with leaders who had a reputation for being good. The consequences for a leader whose people “voted with their feet” included being deposed by the king. In short, my knowledge of my own society conflicted with the theory of popular participation. That triggered an interest in me to go and investigate the extent to which it was feasible. I found that it really is not. Like it or not, traditions and ways of seeing or doing things live very long.

Community participation was a key principle of the Bamako Initiative. Today is seems the Bamako Initiative hasn't quite reached its objectives. What do you think are the main reasons?

There are several reasons. One is that service delivery in health care fails because of factors that go way beyond what participation can address or rectify such as the availability of medicines and human resources in rural areas and the professional supervision necessary for delivering care according to established standards. The idea of wanting to ‘capture’ for the public sector money people were spending on private provision was a good one. However, its weakness lay in assuming that people would be as willing to pay for care in government facilities as they were in private ones. Experience in Uganda has shown that it certainly wasn’t the case. For many poor people, paying for care in government facilities alongside paying taxes was a contradiction in terms. “Why pay taxes and then pay for services as well?’ People knew that owners of private facilities were ‘doing business’ and therefore had to make a profit but the idea that government facilities should do the same clashed with many people’s understanding of what governments are supposed to do, which is provide free health care services. Rather than pay for inferior public services, people naturally preferred the higher-quality and more responsive private provision. The proliferation of private facilities of all sorts made the ‘exit’ from public provision fairly easy. Private providers in the highly unregulated health markets of poor countries are more than happy to provide their clients with the services they want, not necessarily those they need. In the 1990s, Susan Reynolds Whyte found that people in rural Uganda could turn up at drug shops and ask for whatever medicines they wanted in proportions they themselves had determined, in line with the amount of money they had. The Bamako Initiative therefore fell short of its aspirations because it was founded on plausible but questionable presumptions.

Why did community participation propositions such as the Bamako Initiative appear in the late 80s’? Could/should they have been designed differently?

The initiatives appeared at the time they did because there was a desperate need for change. Public provision of health services in much of the developing world was abysmal. There was need for radical thinking, to devise ways of bringing about improvement. Yes, they could have been designed differently. The key problem, as far as I can figure it out, was the one-size-fits-all approach, whereby development initiatives are introduced in every country in exactly the same way, without regard to contextual considerations. Clearly countries are different and cannot possibly follow the same path in the pre-determined ways the development industry promotes. There is something to be said for each country trying to do what fits its context rather than going for so-called ‘best practice’. If countries such as Rwanda have been more successful than others in reforming their health systems in ways that have proved to work for them, it is because, as research by the Africa Power and Politics Programme at the Overseas Development Institute discovered, they went for “good fit” rather than ‘best practice’ solutions. They provide us with the grounds for questioning the tendency within the development industry to promote universalist solutions to problems of development or governance.

You have been a critical voice of community participation and incidentally you come from Uganda - unlike quite a few prominent researchers on community participation who come from North America/Western Europe. Do you think there is a (Western) "doxa" of community participation? Was it mostly a donor fad?

As I indicated at the beginning, my skepticism about participation stemmed from my understanding of how the community I was born in and grew up in functioned, and how things such as leadership were understood. It never derived from theorizing about what is good for poor communities. The trouble with the development industry is that it is dominated by theorists whose understanding of the world or worlds they want to change or improved is limited and informed by short visits and to a large extent superficial interactions with the people whose lives they want to improve. It seems to me as if the problem really is the naïve liberalism of well meaning but misguided outsiders working with insiders who are too willing to play along without asking some hard questions. In my opinion the Rwandans get a lot right by refusing to be dragged along, by questioning and rejecting things they believe will not work for them and going for what works.

Do you think it would make sense to consider using similar mechanisms of community participation in North America/Western Europe?

I don’t think so. For one thing, participatory mechanisms demand lots of people’s time. You cannot expect people in a community to hold all these meetings and make all the decisions; what time would they have left for ‘living’? I have lived in Europe. I never sat in a single community meeting and if anyone had required me to attend as many meetings as my mother in the village in Uganda is required, I would never have had the time to do so. My mother attends very few meetings and misses most for the same reasons. Things in the areas of London where I lived, worked the way they did because the UK has a functioning state. That is what we need in Africa and the developing world, not participation. This is not to say that participation has no value; it does. It can complement a strong, functioning state when people could rise up and express dissatisfaction whenever they may judge it necessary. And in that case, it can only be sustained in a context where the state is responsive. Otherwise people will see no reason to engage in citizen action that produces no results.

If I understand correctly, community participation in social services in Uganda was also quite heavily promoted by the state. What do you think is
the reason? Wasn't it in a sense weakening the state a bit more?

As a fashion in development, participation coincided with the rise to power of the National Resistance Movement (NRM). The NRM leadership had tested the benefits of citizens participating in decision making during the civil war when they organized citizens into local councils in order to enable them to take charge of things such as security and also to vet recruits into the rebel army. The arrangements worked well enough for the Movement to want to apply them to post-war governance once they seized power, not least because they offered a window of opportunity for the state to penetrate the entire countryside, undermine traditional authority structures and entrench itself. Further, the NRM’s rise to power coincided with the early post-cold-war period when democratization and accompanying phenomena such as decentralization were top on the agenda of the donor community. In this sense there was a coincidence of interests between the NRM leadership and the donor community. Two decades down the road, we know that there was a great deal of naivety in assuming that ordinary people actively wanted and were capable of watching over their leaders and questioning as well as directing their activities. I do not think participation weakened the state. Rather, it did nothing to strength states that were already weak. It allowed governments to shirk their responsibility for making things work and to load it onto citizens who possessed neither the inclination nor the capacity for doing so.

In a recent article, you argue that "vertical and horizontal co-ordination, inspection and supervision, and the strength of accountability enforcement mechanisms" are the keys for efficient social services delivery. What is exactly the role of communities there? What is the future of community participation in social services delivery?

Yes, indeed, those are the keys in my opinion. Communities ought to be accorded avenues through which they can pressurize their leaders if they judge that to be the thing to do at any one moment. This could happen if, say, they find the quality of service provision is below their expectations. For this to happen, educational campaigns should be mounted to ensure they know it is their right to do so. This is more or less the situation in Western democracies. People are not required – and I mean required – to participate in decision making on the scale those in poor countries are. However, when leaders make decisions they find objectionable, they have the right to demonstrate or engage in forms of citizen action that put their message or messages across to whoever they are intended for. Even then, we should not expect this change to happen overnight. The kind of activism we see in advanced democracies took root over long periods of time.

It seems to me that popular participation is rarely considered as a political act. From your research and experience, would you say that popular participation is a political act?

Well, if we agree that participation is intended to influence decision making and in a sense even resource allocation, then it is about making a choice between or among competing ideas. It is therefore a political act. That in a sense is also a reason why it is a difficult proposition in contexts where relations between leaders and the people they lead are highly hierarchical and don’t entail direct confrontation or contestation.

On December 12th, a resolution called “Global health and foreign policy” was voted at the United Nations. This declaration, whose main focus is universal health coverage (UHC), triggered a debate on the online discussion forum of the Performance-Based Financing Community of Practice. Most of the discussion focused on the usefulness of such resolutions. Several members are concerned about the possible negative impact in low-income countries. This blog post summarizes the main points of the discussion. 

Collection, editing, titling and introduction: Emmanuel Ngabire, February 4th 2013.


The UN UHC resolution: yet more havoc in low-income countries to be expected...?

The debate was launched on December 13 2012 by Alex Hakuzimana, from Rwanda, when he forwarded a UHC Forward message entitled “U.N. votes in favor of universal health coverage resolution” to the PBF CoP. Exchanges followed each other up very rapidly - by the end of the 1st day of the debate we already counted 12 interventions. Overall, the discussion was constructive, and if occasionally a more offensive style was used, other participants (or the CoP facilitator) tried to refocus the debate in a gentle but firm way. In a very measured response, for example, towards the end of the discussion, Jurien Toonen acknowledged that having this “PBF & UHC” discussion was very valuable, as this is what the CoP is all about. Yet, he also emphasized that the discussion could be even more useful if some structure was brought to it, avoiding a mix up of roles and mandates in the discussion– between international organizations, policy makers in LMIC, implementers, academics and beneficiaries. Surely something to consider in future CoP discussions. But first things first. Who really got the discussion going? Well, Robert Soeters (from SINA Health International) was the first to react to Alex’ forwarded mail – so credit goes to him for triggering the discussion.  Pointedly, he noted that ambitious declarations are all very nice and wonderful but their problem is that they typically do not clarify who will bear the financial responsibilities for all these lofty aims – i.e. “who will pay the bill” - nor do they look at the cost-effectiveness and sustainability issue. He further stressed the risk that populist politicians may confound UHC with free healthcare and launch rather populist policies based on the declaration, the way it happened with Burundi’s pre-payment system, “Carte d’Assistance Maladie” (CAM). In resource-poor settings (like low and middle-income countries), a PBF mechanism can boost cost effectiveness

The issue of “who will pay” was reiterated by different CoP members who also noted that we have seen similar lofty international and national statements and declarations before (like Alma Ata (Health for All) or the Abuja Declaration). In their interventions, not all discussion participants made a clear distinction between UHC and universal health care, not unlike what happens in the general UHC debate.

Laurent Musango from WHO AFRO then intervened to bring attention to the entire health system: changes in one health system component can and do affect other components in different ways, he argued. So the discussion shouldn’t only focus on health financing, but should also take into account other health system components, and preferably so in a synergic manner. With the new declaration, the direction of health systems is clear, though: Universal Health Coverage. Along the same lines, Pascal Birindabagabo added that the UHC momentum should be supported. He also proposed that middle-income and developing countries should mobilize domestic funds to support UHC in their countries.

… or a crucial means to keep governments accountable?

The risk that the UHC declaration remains just a set of fancy words without much operational significance was also recognized by Joseph Kutzin from WHO Geneva. However, he strongly emphasized the importance of such resolutions. His experience has taught him that resolutions like these are tools that civil society organizations can use to hold countries accountable for their commitments. It’s a gentle “stick” to align country decision makers’ actions with the declaration. After highlighting the added value of such UN resolution, Joe also clarified the meaning of UHC as conceived in the World Health Report 2010. In the report, WHO did not say that UHC means “everything for everyone, free of charge”. The definition WHO uses means instead that everyone gets the services that they need, of good quality, and at cost that doesn’t impoverish them. If you operationalize this concept, Joe continued, it’s clear that UHC should be understood as a direction rather than a destination. No country - not even the richest one - is able to fully close the gap between the need for and use of services, but all countries want to reduce that gap, to improve quality and improve financial protection. Context-specific policy measures addressing the health and development priorities of a given country then become possible.

Joe acknowledged PBF has obvious appeal for him as he sees strong potential links between the PBF approach and a core message on health financing for UHC: the need for a coordinated approach to policy rather than single-instrument “magic bullets”. PBF is a means for system building through coordinated policy action. The Burundi experience of linking PBF to free care was a case in point, he argues, as it’s an example of coordinated policy.

Do such lofty resolutions really take our reality into account?

According to Longin Gashubije from the ministry of health in Burundi, UN delegations who promote these declarations in New York tend to live far from the reality on the ground in low-income countries. Since Alma Ata, UHC has been dreamed of but unfortunately not reached in countries like Burundi. This is due to various reasons including repeated wars, expectations which were set too high, weak economic growth, lack of societal and cultural progress etc. All these factors can explain the failure to reach the previous declarations on UHC. To these root causes, Mohammad Muhammad from Nigeria added another factor, corruption. He called on African leaders to open their eyes: they need to realize that UHC is not realistic in corruption-prone countries characterized by a myriad of developmental needs and scarce resources.  Longin also argued that today the financial gap is far too big (more than 50% of the government budget), and as two thirds of the people live below the poverty line, government priorities can’t be too ambitious in countries like Burundi and should focus on the poor’s needs first of all. Obviously, the health financing burden is too heavy for the government, and Burundi’s partners will have to step in, he continued. But external resources can’t solve everything. Cultural progress is at least as important, he concluded.

Seize the global window of opportunity, promote good practices

Bruno Meessen from the Institute of Tropical Medicine at Antwerp then chipped in. In his opinion, the UHC resolution goes in the right direction as it opens the window of opportunity even further for the CoP members who develop better health care financing systems at country level. Bruno also advised CoP members to read again carefully the WHO Report 2010 as it clearly stresses the need to find mechanisms to be more efficient with resources. Hence, PBF can and should capitalize on the current UHC momentum, even more so now that the world is increasingly moving away from simple “blue prints”. The complexity of UHC and the need for context-specific approaches are more and more acknowledged nowadays. Furthermore, Bruno reminded people that the declaration is not just relevant to Africa but also to middle-income countries, where UHC has gained momentum recently in countries as diverse as China and Mexico. UHC is even relevant for high-income countries like the US (“Obamacare”), so it’s very much a Universal Declaration. Like many other economists, Bruno also hopes that in a not too distant future, the fiscal space for UHC will  increase in many African countries. Soon, ministries of finance might invest national resources and increased revenue more in innovative schemes like PBF, he argued. Nevertheless, he agreed that in many African countries we need more than just nice words. In this respect, he also referred to the perspective of the AIDS movement, which is apparently also not very happy with the declaration, as the declaration’s section on “sustainable financing mechanisms for universal health coverage” fails to mention international health financing.  Many AIDS advocates ((like Gorik Ooms)  call instead for a mechanism enforcing structural transfers from rich countries to poor countries, from a right to health perspective.

Robert Soeters made a second intervention on December 14th pointing out the consequences of - what he called - the “sweeping generalized statements” of these declarations. Country realities differ in terms of resources, organization and culture, yet, lofty declarations often inspire Ministries of Health or Presidencies to ignore this reality. Robert emphasized that this may then create opportunities for populist decisions that can destroy the quality of existing health services. He gave the example of Burundi where the CAM pre-payment system was promoted and “conceptually endorsed by WHO” without defining how to finance it. The predictable result was the degradation of health facilities and reference to extremely expensive private services.

On the responsibilities of those setting the agenda at global level (and WHO in particular)

In his opinion, advocates of UHC should develop more realistic and responsible proposals adapted to the context of low- and middle-income countries. Efficiency also matters, Robert argued, and there he called on international organizations such as the WHO to also consider PBF as this approach has increased the motivation of many people in low-income countries. Alluding to 2011 skeptical articles in the WHO Bulletin and a recent Cochrane Review (which basically concluded “we need more evidence”) he stressed that criticism of PBF without coming up with good alternatives on how to finance quality health services is rather irresponsible – in fact, it can lead to situations like in Zanzibar MoH, where, despite quite some initial enthusiasm about PBF, they are now in a health policy limbo as they were told to doubt PBF given recent literature on the approach. Dr. Soeters encourages debate about social aims in the PBF CoP, but only if necessary nuance on cost, efficiency and sustainability is foreseen. In his opinion, for example, the sustainability of health systems requires that they cannot be simply financed by external aid agencies in LICs.

In a second intervention, Joseph Kutzin then explained that UN resolutions by their very nature cannot contain details like sources of funds. They are inevitably a compromise and can’t be very specific, that’s the price you pay for broad support. So it’s important to have realistic expectations about what can come from a UN resolution. The resolution is a sign of growing political support for Universal Coverage, Joe said. These declarations do not provide details but, they are nice instruments to hold governments accountable and they can be more powerful when picked up by – national and/or international - civil society groups.

Joe also rebutted some of the claims Robert Soeters made about so called “WHO positions”. Unlike what Dr Soeters implied in his intervention, WHO did not “conceptually endorse” Burundi’s CAM, as this is a voluntary health insurance arrangement. Both the WHR 2010 and Kutzin’s recent article in the Bulletin made it abundantly clear that voluntary health insurance is not a viable path to universal coverage.

According to Joe, Robert also suggested WHO is not very interested in efficiency. In response, Kutzin referred to the World Health Report 2010 where a whole section (“more health for the money”) focused on efficiency. He also referred to his recent Bulletin article in which he also argued that you can’t simply “spend your way to universal coverage”; costs have to be managed and addressing the leading causes of inefficiency need to be priority targets for reform.

A good dialogue requires a common platform but also an understanding of our respective roles

The debate continued with a contribution from Bruno Meessen connecting the positions of decision-makers and technicians. He reminded CoP members that getting the voices of practitioners and implementers heard is a major concern of (and in fact one of the rationales behind) the PBF CoP. He acknowledged the frustration caused by inappropriately designed and underfunded policies and mentioned that too often country leaders fail to listen to their technicians. He highlighted that nevertheless, political leaders willing to introduce UHC should be fully supported as they can mobilize their citizens. So PBF proponents need to surf on the current UHC wave. Also, bridges with decision makers need to be built so that technicians will be heard in time and mistakes prevented. He believes one day the CoP – intended as a platform to bring together agenda setters, policy makers and implementers – will ensure such a relationship of trust. Having said that, for the moment the emphasis of the UHC movement is too much on agenda setting, Bruno continued. It’s time to match this with an equal effort to address the stages of policy formulation and implementation: the ones in charge of formulation and implementation also need to be supported and properly resourced.

Jurien Toonen (KIT, Amsterdam) then highlighted the need to bring some structure to the discussion, and avoid a mix up of roles and mandates in the discussion on health financing and providing care and social protection, between international organizations, policy makers in LMICs, implementers, academics, advocates and beneficiaries. He elaborated on the role and mandate of each of these actors. International organizations have a role in developing a vision and strategies to bring coherence to different types of health strategies. Alma Ata, Investing in Health (World Development Report 93), the MDG for Health,… all provided impetus, even if they all had flaws. Now, perhaps one might think UHC is “the world’s new flavour of the week”, but it is because the world has learned something: UHC is more health system-wide than its predecessors, and pays more attention to the most vulnerable people. Or as Tim Evans put it in Bangkok: UHC’s starting point is “the unbearable injustice that too many have no access to health care”. Anyway, there’s no need to blame international organizations (and certainly not WHO) for providing vision, Jurien argues. As for policy makers in LMICs, they have chosen to embark on UHC, even if they live in countries not comparable to China and the US. They might struggle to make it happen, but the good news is that they are finally more able to get the Ministry of Finance interested in health care because of UHC. Unfortunately, the Ministry of Finance people often think, wrongly, that UHC is like free health care or health insurance, but things are improving. In many countries, a dialogue is starting on sound health financing – stakeholders are trying to find the right mix between different health financing instruments (tax-based and other ones). Implementers will suffer the most, Jurien argued, if design issues are not well addressed. PBF also suffers from design and implementation issues in several places, and they need to be overcome. There’s also no need to blame the academics, Jurien continued. Academics are there to provide evidence if PBF works, and if it works, why, how and where it works. The same is true for UHC by the way. Support for either PBF or UHC should thus be based on evidence, and this evidence should be challenged by implementers, strategists and other academics. Instead of lamenting a Cochrane review because it comes to the conclusion that evidence on PBF is thin, we need to take up the glove and make evidence strong, Jurien argued. Even if you know that things “work”, evidence is necessary to prove it. He reminded CoP members that research can support successful implementation like in Thailand, where implementing UHC was much underpinned by academic work. As for the advocates then, they should do what they do best: communicate, bring up discussions, even in a provocative way, make people think and react. But as advocates, they have limitations, just like the other actors do. Finally, UHC is all about the beneficiaries, “the man and woman under the baobab”, as Jurien called them, and their health status. That group, their interests, should be the starting point for the discussions.

An illustration of UHC and some clarifications on the CAM in Burundi

In other interventions, debaters clarified the concept of UHC further (Bruno Meessen, Gyuri Fritsche, referring to a field visit to Mayo-Ine Health Centre in Adamawa State in Nigeria, “This is what UHC is about: to find customized solutions to get more people accessing services, and to have metrics to prove it”, …). More clarification was also provided on the health insurance scheme in Burundi (by Olivier Basenya, Longin Gashubije, Bruno Meessen). Olivier underlined that CAM is a health assistance system rather than health insurance and he explained steps undertaken since its introduction in 1984 to improve its efficiency towards UHC.

Conclusion

After a wide-ranging and generally respectful discussion, it emerges that the UN resolution provides an opportunity for civil society organizations to put decision makers under pressure and hold them accountable. In addition, UHC provides an obvious opportunity for PBF proponents too, if we think strategically. Jurien Toonen summarized the window of opportunity like this, for example: “If we want to head for UHC, we will need health services that perform well, hence PBF”. Some challenges to implementing this declaration were also pointed out, however. Debaters mentioned the distance to the reality on the ground, endless wars, unrealistic expectations, cultural issues, inadequate (both domestic and international) financing, corruption etc. Nevertheless, one can hope that fiscal space for UHC in African countries will improve in a not too distant future. Finally, the discussion also emphasized the role of research in supporting implementation and providing more evidence on what works, how and why.

The debate was suspended on December 17, 2012 when the CoP was informed of the death of Guylain Kilenga who was participating in a PBF training course at Bujumbura. RIP.

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).

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.