CHAPTER 3 What is Participation? - Source

1 37 what IS CBR IN THE AFRICAN CONTEXT? CHAPTER 3 what isParticipation?Susan B. Rifkin, Maria CHAPTER presents arguments as to why participation is importantfor improving life situations, particularly for the poor and disadvantaged,including people with disabilities and their families. It begins by notingthat the contribution of participation to health development is not easilyagreed upon. It then, outlines the reasons for participation in healthdevelopment and how this has affected the development of communitybased rehabilitation programmes. Ways of defining and assessingcommunity participation are discussed. The penultimate sectionidentifies critical issues that must be addressed in consideringparticipation as a basis for CBR programme planning, giving examplesfrom the Ugandan context.

2 The conclusion points to the complexity andchallenges that participation presents, for planners and managers ofcommunity based health and disability is no agreement among planners and professionals about thecontribution of community participation to improving the lives of people,particularly the poor and disadvantaged. Some completely dismiss itsvalue altogether, while others believe that it is the magic bullet , thatwill ensure improvements especially in the context of poverty this lack of agreement, community participation has continued38 CBR A PARTICIPATORY STRATEGY IN AFRICAto be promoted as a key to development. Although advocacy forparticipation waxes and wanes, today, it is once again seen by manygovernments, the United Nations agencies and non-governmentalorganisations (NGOs), as critical to programme planning and povertyalleviation (World Bank, 1996).

3 REASONS FOR COMMUNITY PARTICIPATIONC ommunity participation has been a constant theme in developmentdialogues for the past 50 years. In the 1960s and 1970s, it becamecentral to development projects as a means to seek sustainability andequity, particularly for the became a central plank for health policy promoted by the WorldHealth Organisation, in its conference in Alma Ata in 1978 (WHO/UNICEF, 1978). In accepting Primary Health Care as governmentpolicy, all members of WHO recognised the importance of involvingintended beneficiaries of services and programmes, in their designand implementation. The following reasons for this acceptance wereput health services argument: the services provided are under utilisedand misused, because the people for whom they are designed arenot involved in their economic argument: there exists in all communities, financial,material and human resources that could and should be mobilisedto improve local health and environmental health promotion argument: the greatest improvement in peoples health is a result of what they do to and for themselves.

4 It is not theresult of medical social justice argument: all people, especially the poor anddisadvantaged, have both the right and duty to be involved indecisions that affect their daily lives (Rifkin, 1990).Planners and managers cannot agree upon the contribution ofcommunity participation to health IS Participation? The process of service development for people with disabilities, indeveloping countries namely, Community Based Rehabilitation (CBR),arose out of the philosophies of Primary Health Care (PHC). It wasrecognised that institutional rehabilitation was not meeting the needs ofpersons with disabilities in the world, and in the Alma Ata declaration(WHO, 1978), rehabilitation was added as the fourth component of PHC,together with promotion, prevention and curative Toole (1996, pp13) points out that the emergence of the PHC conceptentailed acceptance of two that it is more important tobring about small improvements among the entire populations than toprovide highest standard of care for a few privileged and nonprofessionals with limited training could provide crucial services .

5 As a result, the World Health Organisation (WHO), who were thearchitects of CBR, built it on the premise that there would be a transferof information and rehabilitation skills to people with disabilities andtheir families. Members of the local community would also be involvedin the planning and decision making of these programmes (Helanderet al, 1989).Through the 1990s, additional emphasis has been placed on communityinvolvement in planning, decision-making and evaluation (Mitchell 1999,Sharma and Deepak, 2001). It has also been recognised that CBRpartnerships can utilise resources in the community to reach largernumbers of persons with disabilities (Lang, 2000).

6 Twenty-five years of experience in development work, both in healthand disability, finds these arguments still relevant. In the present politicaland economic climate, organisations such as the World Bank havemodified these reasons to pursue the objectives of both, equity andsustainability. These modifications reflect the experiences of particularlythe international development agencies. They also reflect the influenceof strong advocacy for participation from people like Robert Chambersand other promoters of PRA/PLA (Participatory Rural/Rapid Appraisal;Participatory Learning Approaches) (Chambers, 1994).40 CBR A PARTICIPATORY STRATEGY IN AFRICAThe World Bank s reasons for community participation people have a great amount of experience and insight intowhat works, what does not work and local people in planning projects can increase theircommitment to the local people can help them to develop technical andmanagerial skills and thereby increase their opportunities local people helps to increase the resources available forthe local people is a way to bring about social learning for both planners and beneficiaries.

7 Social learning meansthe development of partnerships between professionals andlocal people, in which, each group learns from the other (WorldBank, 1966).Some arguments for including participation in health anddisability programmes are:1. People know what works for them and professionals need tolearn from People make contributions of resources (money, materials,labour) for these People become committed to activities that they have People can develop skills, knowledge and experience that willaid them in their future OF COMMUNITY PARTICIPATIONA lthough many people agree that community participation is critical indevelopment programmes, very few agree on its definition.

8 The variousdefinitions are:41 what IS participation ? Voluntary contribution to public programmes but people do not playa role in shaping the programmes. Involvement in shaping, implementing and evaluating programmesand sharing the benefits. An active process where intended beneficiaries influenceprogramme outcomes and gain personal growth (Oakley, 1989).In the field of health and disability, perhaps a more concrete dissectionshows the differences in definition and understanding of the might suggest that planners/professionals in this field have looked atcommunity participation in three distinct ways (Rifkin, 1985).Definitions of community participation range from peoplepassively receiving benefits from health/disability programmesto people actively making decisions about the programmepolicies and first is the medical approach whereby, health is defined as theabsence of disease and community participation is seen as doing, whatthe doctor ordered.

9 The second approach is a health planning approach where health isdefined in the World Health Organisation s term of, not merely theabsence of disease, but also the physical, social and mental well-beingof the individual . In this context, community participation iscontribution to the delivery of a health service by contributing money,materials and human third approach, is that of community development where health isdefined as a human condition and community participation as activeinvolvement in decision making and accountability for three views correspond with frameworks drawn from thoseinvolved in rural development thinking.

10 The following table illustratestwo additional aspects of defining participation that of interactionbetween professionals/planners and community people and the processof developing community A PARTICIPATORY STRATEGY IN AFRICAA pproachModelProcessMedicalComplianceMarg inal ParticipationHealth PlanningContribution/SubstantialCollabor ationparticipationCommunityCommunity ControlStructural ParticipationDevelopmentPractice of Community ParticipationThe table above illustrates the different approaches. They should not beseen as mutually exclusive. It is perhaps better to see them on a continuumthat at one end has information sharing and at the other, there is no one definition of the concept, the continuum presents aframework, which allows the range of views to be accommodated.