Community-based health care and development: exploring the myths
Adnan A. Hyder
Assistant Scientist, Department of International Health, School of Public Health, Johns Hopkins University, 615 North Wolfe Street, Suite E-8132, Baltimore, MD 21205, USA
Sir Health, especially the health of children, is a well-recognized entry point for development. There are myriad pathways for moving towards development from health interventions, as demonstrated by pilot projects around the world. Community-based health care has been promoted as the solution to health problems for several decades. This approach gained momentum with the primary health care movement as promulgated by the Alma-Ata conference in 1978, which has also generated valuable insight into the healthdevelopment relationship. And yet, the same challenges and inequities still remain in the developing world (1). Community-based health care has been plagued by principles which have become myths in the context of a changing environment.
Myth: there is a universal model. There are many models, which can and will achieve development objectives, given a specific geographical situation and time frame, and they all need to be acknowledged. The search for a universal model thus needs to be changed to recognition of plurality. This will allow for a pluralistic paradigm in health, where local circumstances in the context of regional and national priorities can determine the appropriate model for health development. Each community must be allowed to participate, within its own constraints, and allowed to grow as its members determine their future for themselves.
Myth: focus on the village. Acceptance of a plurality of models recognizes that the traditional concept of village-centred development needs to be re-evaluated. Villages are interconnected to each other and are increasingly connected to towns and cities as improved communication and transport move all parts of the world closer to each other. This interconnectedness needs to be seen and used by the population as a positive change for their benefit. By acknowledging and preparing for this change the capacity to confront its challenges will also be developed. The village exists within a sub-district, district, state and country, and there are integral relationships between these entities. They are the foci of decision-making and power allocations, especially from the public sector point of view. They therefore need to be recognized within the development framework, and the capacity of people to act in their interest at each level must be improved. An unnecessary focus on the village as the locale for action will not serve the current context of health development.
Myth: governments are the problem. The government must be viewed as a full partner in the development framework (2). Nongovernmental organizations and the private sector can be important actors in the health field, and parallel systems of health care are very common in areas where they have been working effectively for many years, but they cannot replace the government (3). The lack of efficient public programmes created the need for people to act, and such responses have been critical, but nonetheless the challenge remains to help governments to develop programmes. In the end it is the people who have influenced the way governments behave and take decisions.
Myth: community-based programmes are less expensive. The real costs of community-based health programmes are often not visible and are sometimes overlooked. Rigorous cost analysis and eventually cost-effectiveness analysis need to be done to define the specific value-for-money contribution of interventions. Programmes are too quickly dubbed cheap and effective before they have been properly evaluated. On the other hand, this does not mean that they have to be driven by costs alone. The cost and cost-effectiveness arguments may be challenged by arguments of equity or need, as long as they are made explicit and transparent. Reasons for conducting the programme will then be evident and understood by all.
The focus of efforts must no longer be on trying to develop new prototypes of community-based health care or on going to scale with current models. The challenge is to recognize the value base upon which the notion of community-based health care stands. A value system that stresses equity, empowerment and respect must be the guide for responding to health challenges in different parts of the world. A model is appropriate if it can serve the people of that community (however they are defined) on the basis of such a value system. If the set of values is common, then the focus of community-based health care, primary health care, and all such approaches becomes clear. This value base is also the intersection with evidence-based health care. The overriding need is for recognition of the plurality of pathways to operationalize the value base from which efforts for health and development emerge.
1. The 10/90 report on health research. Geneva, Global Forum for Health Research, 1999.
2. World development report 1993. Investing in health. New York, Oxford University Press for The World Bank, 1993.
3. The world health report 1999 Making a difference. Geneva, World Health Organization, 1999.
Adnan A. Hyder
Department of International Health, School of Public Health, Johns Hopkins University
615 North Wolfe Street, Suite E-8132
Baltimore, MD 21205, USA
Tel: 410-955-3928. Fax:410-614-1419