Community Empowerment for Health
Lessons from the Rural Health Development Project in Nepal
Von Biren P. Bangdel / Direktion für Entwicklung und Zusammenarbeit DEZA
In Nepal, the existing health delivery system is still ineffective in reaching out to the rural people for a number of reasons. The Rural Health Development Project (RHDP), jointly funded by the government and the Swiss Agency for Development and Co-operation SDC and operational in Dolakha and Ramechhap districts has tried to facilitate the local health delivery system in becoming more accountable towards the people. Community empowerment is what the project has tried to achieve in order to make the system not only accountable but sustainable too.
Conceptually, the existing Nepalese health delivery system at the local level is excellent in terms of its institutional set up. The establishment of Sub-Health Posts in every Village Development Committee (VDC) and Health Posts in every Ilaka level – a cluster of 3 to 5 Sub-Health Posts - in order to provide health services to the rural people has been a commendable job of the government. In every Sub-Health Post, a team of one Auxiliary Health Worker, one Village Health Worker and one Mother Child Health Worker is a very good combination of health staff responsible for day to day health delivery services. Likewise, the Health Post’s staff consists of one Health Assistant, one Auxiliary Health Worker, one Auxiliary Nurse Midwife and one Village Health Worker.
But most commonly, only the curative services are handled by these periphery level health institutions, and there is still a long way to go in order to improve the existing local health delivery system. The management committees formed by the government to look after the management of Sub-Health Posts and Health Posts are generally inactive. Majorities of the rural communities are not even aware of the committee’s existence, forget about its roles and responsibilities. In most cases, the Village Development Committee’s chairpersons handpick most of the members. In other words, the Community have nothing to do with the selection of the members of the committee. So where does the accountability lie?
One simple example related to ownership is cited here. The drugs for each Sub-Health Post and Health Post supplied by the government do not meet the local requirement of the whole year. Consequently, the uses of Sub-Health Post or Health Post services become negligible as soon as the drugs are finished. Who is responsible for this? Is it the Sub-Health Post or Health Post in-charge who should take responsibility to fill up the empty drawers with necessary drugs? Is it the Village Development Committee’s Chairperson who should be responsible? Is it the District Health Office who should think that it is their responsibility? So the question of responsibility of providing drugs to the rural people throughout the year with or without costs through the Sub-Health Posts and Health Posts remains unanswered.
Rural Health Development Project RHDP:
Awareness and empowerment
The crux of the problem in the existing local health system is the lack of awareness of the local people about health and their participation in promotive, preventive and curative aspects of health activities. Time and again it has shown that there must be the people's involvement in every kind of development activities. How could they be actively involved was the prime concern of the Rural Health Development Project RHDP. Keeping this in mind, the project had designed a working approach four years ago and put it in place with a team of very experienced and well trained field facilitators. They are people from the working areas or localities and are stationed in each working Village Development Committee. This approach looks a very simple one but it involves a rigorous process requiring a lot of patience and time.
Without disturbing the existing structure of health system, the following steps are carefully carried out one by one by the RHDP:
Orientation to elected members of the Village Development Committee on the local health situation and the role of the Committee in health management: This is to raise the elected members’ awareness level related to health issues and make them understand their roles and responsibilities towards the local health system.
Reformation and organization of management training to executive members of existing mother groups: These mother groups, at least nine in each Village Development Committee, play a very crucial role in raising awareness of women of their villages on health issues. In order to increase their management capacity, a three days management training focusing on leadership, communication, problem solving and management of local resources is organized for all the executive members. They are also facilitated to analyze their health problems, prioritize thus identified problems and find solutions using Participatory Rural Appraisal tools.
Organization of management training to Female Community Health Volunteers: Being the member secretary of each mother groups, these Female Community Health Volunteers facilitate mother groups to hold regular meetings and also provide health education during the meetings. The Training provided to them is focusing on health education methodology. This is to help them to increase their confidence in effectively conducting health education related to the common health issues.
Training to teachers on the management of school health programmes: The purpose of this is to help the concerned teachers to effectively organize and manage school health activities in their schools.
Training to Faith Healers on health education and the referral system: In the rural areas, people first go to Faith Healers when they get sick. Realizing this, all the Faith Healers were provided with two days training in close collaboration with government health workers focusing on health education methodology and when and why to refer patients to nearby health institutions for further treatment.
Management training to health workers on facilitation skills, reproductive health, gender and HIV/AIDS: This is to upgrade their existing knowledge and skills in order to make them capable of delivering quality health services.
Facilitation in organizing meetings and workshops to link Village Development Committees, Sub-Health Post and Health Post health committees, mother groups, Female Community Health Volunteers, Traditional Birth Attendants and daily clinic operators of the Primary Health Care Outreach Clinics: Facilitating these partners to regularly hold meetings would create a healthy working environment.
Reformation and management training to the VDC Health Co-ordination Committee members: This committee is responsible for the overall management of the local health system. A three days training focusing on management, leadership, communication and resource mobilizations is organised for committee members in order to increase their management capabilities.
Facilitation to VDC Health Co-ordination Committee to utilize the VDC's technical and financial resources for health improvement of the entire population. This is to support the committee to identify resources for carrying out health related activities. The Rural Health Development Project has made a provision of contributing 20 % towards the total cost of any micro projects that are beneficial to a larger number of the population. The other 80 % comes from VDC’s fund and or from the groups. So far more than one thousand health related activities have been implemented.
Effectiveness of health services
Improving the existing local health delivery system is still an ongoing activity of the Rural Health Development Project. However, the hypothesis it was working on when it designed its current working approach four years ago has been proved: It does not require any new model and approaches to make the existing health delivery services effective and accountable to the local people. It simply needs to identify the weaknesses in the existing system and strengthen it through the above mentioned facilitation activities.
There are health institutions, individuals and groups who are, directly or indirectly, singly or collectively, providing health services to the people. After completing the above mentioned facilitation activities, RHDP then facilitates the trained Female Community Health Volunteers, Faith Healers, Traditional Birth Attendants, school-teachers and other committed social workers to identify and select capable representatives to represent them in the VDC Health Co-ordination Committee and make them responsible for the management of health services of the entire VDC. So far, 48 % of 106 VDCs have VDC Health Co-ordination Committees and are actively implementing health activities.
The existing health delivery system at the periphery level needs to be supplemented with an empowerment process. This process demands a simple working approach and well trained field level staff with excellent facilitation skills. So far, 406 mother groups, 590 Female Community Health Volunteers, 266 Traditional Birth Attendants, 259 school teachers, 102 VDC Health Co-ordination Committees and 135 clinic operators have been trained in the management of the local health services in the last four years.
Unless the Community people are properly facilitated to be empowered, the ownership of local health delivery system remains to be nowhere. The Rural Health Development Project, in general, is organizing training to grass root level working partners and health workers through its district level working partners Women Development Office, District Education Office, District Health Office and District Development Committee. This collaborative effort has been very effective in terms of strengthening the capacity building of government staff who, in turn, would be able to provide training in their own even in the absence of RHDP. This is one of the prime concerns of the Rural Health Development Project in terms of sustainability.
*Biren P. Bangdel is Deputy Project Manager of the The Rural Health Development Project RHDP.