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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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.

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. 

25 years ago, between the 3rd and the 7th of August 1987, the WHO organized an interregional meeting in Harare. The meeting, which was about the implementation of primary health care (following up of the Alma Ata conference in1978), ended with a statement that is known (or forgotten!) today as the Harare Declaration. By establishing the health district model as a reference strategy to organize and develop health services, this event shaped health systems in many poor countries. This strategy particularly shaped health service provision in rural Africa.

A few weeks later, UNICEF organized another regional meeting in Bamako. It went down in history as the Bamako Initiative. Its content is better known: it marked the introduction (or formalization) of user fees and that of community participation in resource management, including essential drugs now sold to users.

Like the vast majority of policies, these proposals were based on pilot experiments or similar approaches already in place in some countries, for example, the "health shops" of Mali (cost recovery) or the experience of health zones in Zaire (health district strategy).

25 years have passed. Globalization and new information technologies have profoundly changed the environment. The structural adjustments of the 80s are long gone. Today the continent is experiencing the strongest economic growth. Some countries have been able to exploit this new phenomenon for major changes in their health system and its financing. Rwanda has shown that the goal of universal coverage is not insane. But the continent is far from being homogeneous. HIV / AIDS is ravaging southern Africa. For the Horn of Africa to Central Africa and a fraction of West Africa, these 25 years have been plagued by armed conflicts. These shocks, coupled with the effects of the global economic crisis of the 80s, have been particularly harmful to health care systems. Many would argue that the potions that were administered to patients (structural adjustment programs, privatization, introduction of user charges...) have not helped, moreover, had long-term side-effects on health systems.

In the coming months, several communities of practice affiliated with “Harmonization for Health in Africa” (in 25 years, agencies have also realized the need to coordinate better!) will collaborate to develop a collective reflection on the Harare Declaration and Bamako Initiative. Several organizations have already indicated their willingness to be partners in this endeavor (if you work for an agency or an international organization and would like to help, please contact us). Like us, they believe that the issues identified in Harare and Bamako 25 years ago are still valid, although some updating is required.

We hope that this process can lead to a regional event in 2013. In the meantime, our intention is to tap our different technology platforms, especially this blog and our online discussion groups, to progress in the reflection.

This text is more than just an announcement of things that we will be producing. It is primarily a call for your contribution and input. They can be modest, such as helping us to widely spread our debates and discussions to people you know, or more ambitious, such as writing an article or a blog post or conducting an interview.



We count on your enthusiasm!