Abstract

Although community involvement in health related activities is generally acknowledged by international and national health planners to be the key to the successful organization of primary health care, comparatively little is known about its potential and limitations. Drawing on the experiences of two middle hill villages in Nepal, this paper reports on research undertaken to compare and contrast the scope and extent of community participation in the delivery of primary health care in a community run and financed health post and a state run and financed health post. Unlike many other health posts in Nepal these facilities do provide effective curative services, and neither of them suffer from chronic shortage of drugs. However, community-financing did not appear to widen the scope and the extent of participation. Villagers in both communities relied on the health post for the treatment of less than one-third of symptoms, and despite the planners' intentions, community involvement outside participation in benefits was found to be very limited.

PIP:

During the summer of 1992, data were gathered through household and personal interviews in two isolated villages in western Nepal to compare a state- and a community-sponsored health center. The Ghandruk Community Health Centre was established in 1987 by a local nongovernmental organization (NGOs) and the Sikles health post was established by the Indian government in the mid-1950s. A comparison of the health-seeking behavior in each village showed that both health centers accounted for only about 30% of treatment, that 40% of illnesses were self-treated, and that 26% of illness in Ghandruk and 35% in the poorer Sikles remained untreated. In each village, more than 90% of the sample was unaware of the existence of a health committee and the health committees were afforded very low status compared to other committees (such as the forest committee). Health committee members were more active in Sikles despite the fact that the health post was controlled by district/regional health authorities. Health workers were more readily identified than members of the health committees but they performed only a few of their educational and health promotional tasks. Village health workers appeared to be inactive, and none of the trained traditional birth attendants were practicing. While the two villages showed no differences in participation in the delivery and use of health services, villagers in Ghandruk have been active in health-related activities such as the construction of private latrines, the development of a water supply, and regular clean-up campaigns. In Sikles, where such interventions have yet to be accomplished, the morbidity rate in the sample population was 81%, compared with 23.9% for Ghandruk. These results lead to the following observations: 1) the applicability of a participatory approach to development in rural Nepal is questionable from a cross-cultural perspective, and 2) the existence of socioeconomic and cultural hierarchies in the villages combined with male domination of the health committees prevents health committees from representing the needs of the entire community. In conclusion, community financing did not appear to increase community participation in the delivery and use of health services or to result in greater equity in health care. Rather than leading to abandonment of this financing option, however, these results should help lead to the creation of a proper balance between the role of government, NGOs, and community self-help in the delivery of health care.