Community Participation: Lessons for Maternal, Newborn, and Child Health

This article from The Lancet, Volume 372, Issue 9642, revisits the Alma-Alta Declaration on the subject of primary health care for reduction of maternal and child mortality. It reviews evidence through examples of community mobilisation that reduced maternal and infant mortality and proposes that "[s]trategies to improve maternal and child health should... involve the community as a complement to any facility-based component."

The article offers definitions of participation, mobilisation, and empowerment, and reviews historical evidence leading to the Alma-Alta Declaration. It describes projects which were participatory, but were not chosen for scale-up when the simpler provision of health commodities with proven effectiveness - such as oral rehydration solution for diarrhoea, cotrimoxazole for childhood pneumonia, vitamin A supplementation, insecticide-treated bednets, and vaccinations - showed clear evidence of effectiveness. However, based upon examples included in the article, the authors state that there is a controversy on community mobilisation versus home care visits in the case of maternal and infant health. Some of the study's conclusions include the fact that community mobilisation is now seen as an effective method for promoting participation and empowering communities, and has been a focus of HIV prevention and treatment programmes at the community level. They suggest that mobilisation has garnered interest as being cost-effective for scale up of care.


The process of community mobilisation, as described here, can take the following path: "The impetus to address ...causes of ill-health began when there was sufficient support to form a community of interest. This community started a process of capacity building - community empowerment - toward gaining more control over the decisions for resource allocation... or ...decision making, such as the development of policy or legislation. The key to the success of community empowerment was the moment when the community engaged with the problem-posing, problem-solving process, and recognised that they could collectively change their circumstances." However, the following needs further research: "What is not known is to what extent peoples' involvement can actually increase resources to support health care, whether participation can create a genuine social learning partnership between people and professionals, whether community mobilisation can really change a commitment to social justice and democracy, and whether community mobilisation can actually accelerate progress at scale toward achievement of MDGs [Millennium Development Goals] 4 and 5 in high-mortality, resource-poor settings."


Community-level mechanisms to bring about improvement can include: 1) changes in behavioural risk factors such as home care practices and decisions about care seeking; and 2) changes in socio-environmental risk factors by developing the capacities of communities, the choices they make, and their ultimate empowerment.


This second mechanism can include:
• increasing capacities within communities, such as the ability to identify maternal and neonatal health problems and their root causes;
• the ability to mobilise resources necessary for improving the health of mothers and newborn infants; the internal and external social networks they can draw on when needed;
• the development of strong local leaders who have the motivation and drive to improve maternal and neonatal health in the community;
• making fundamental choices at the community level to improve their health, such as about the equitable sharing of resources needed for better maternal and neonatal health; about planning feasible strategies to address maternal and neonatal health problems; about planning, implementation, evaluation, finances, and reporting of programmes; and about which people and organisations to approach to address problems.


The authors conclude that, alongside facility-based medical intervention for maternal health, the evidence supports a more central role for community mobilisation. Further, they address scale up:
• "Scale-up of health interventions might involve increasing coverage by geographical expansion, adding technical interventions to an existing programme, advocacy to change policies, and strengthening capacity with more resources, new alliances, and technical skill....
• Several approaches have been used including: government directed and implemented programmes; partnerships between government and non-governmental organisations; so-called living universities and centres of learning; dissemination of methods and results through manuals, training packages, internet, radio, video, TV, and university classes; and organic spread from community to community through word-of-mouth or direct observation....
• [A] favourable environment for scaling up can be created if national policies are in place which support community mobilisation. Programmes are more successful if they communicate from the same system. This success can be achieved by seeking to understand and take into account the social norms and local cultural context around health, community participation, gender roles, use of health services, and household decision making. Importantly, programmes should not cut out or limit essential steps such as problem identification, prioritisation, and strategy formulation by communities....
• [Those working in community health] must have: credibility in the communities; language skills and cultural sensitivity; knowledge of community structures and protocols; interest in being a facilitator and in maternal and newborn health; affiliation with and support from an organisation; good interpersonal communication skills; and availability of time to do the work....
• The main programme cost is building human and community capacity, which needs adequate investment. Partnerships of government, non-governmental organisations, private sector, and community-based organisations are essential, but can face differences in organisational cultures and values, competition for resources, and varying levels of capacity.
• Successful programmes define roles and responsibilities clearly, allocate resources fairly, and establish operational guidelines, communication systems, parameters for implementation, and mechanisms for dealing with problems or disputes.
• Finally, new technologies such as community radio, mobile phones, internet, and digital and video cameras have rapidly become more accessible and could present new opportunities for communication, gathering information, organising, coordinating, and increasing participation."

(Footnotes have been removed by the editor.)