Community Empowerment Strategies in the Community Led Sustainable Health Project Phase II

1. Introduction

Village Education Resource Center (VERC), a Bangladeshi non-governmental organization (NGO), with the support from Simavi, a Dutch non-governmental health organization has been implementing a community led sustainable health project (CLSHP) in the three unions of Lalmohon upazila under Bhola district for three years from July 2006. In July 2009 the project was reviewed. The review report recommended for the continuation of the project with revised design, providing more emphasis on community empowerment for achieving the purpose of the project. Accordingly the second phase of the project was designed expanding to cover the entire Lalmohon upazila with the goal of institutionalizing an effective community managed sustainable health service accessible to all sections of people focusing on poor women and children in Lalmohan upazila attaining improved hygienic practices and health situation. Objectives of second phase are:

  • To bring long term change in behavioral practices by raising community awareness on health and hygiene issues and hence improve the general level of health.
  • To provide access to quality, affordable, sustainable health services in response to the beneficiaries’ needs.
  • To ensure that all members of the community, regardless of gender, age, disability or socio-economic situation have full access to the services available and participate fully in community led initiatives.

The project aims to undertake three prong strategies. First one is massive community awareness for preventive and promotive aspects of health, so that they can control their behaviours and environment resulting minimum sickness. For this, community will be segmented into children, adolescents’ boys and girls and adults male and females. Each of them will be made aware on different preventive and promotive health issues using multi-channels. Second strategy is to make the community aware about the different services available to them from government and NGO sectors for needed utilization, empower community representatives to negotiate with the service providers and their controller for re-scheduling the services to best suit with communities need and play watch-dog role for the services, so that communities are guaranteed with sustainable services.  The third among the strategies is to provide need based services to meet the requirements of the special groups of the community – located in difficult geographical locations, ethnic groups, marginalized communities etc.

Though both the first and second strategies mentioned above aim for community empowerment, and since the first strategy will be elaborated under community IEC/BCC strategy, the second strategy mentioned above will be elaborated under this community empowerment strategy.

 

 

2. Community Empowerment

Community empowerment refers to the process of enabling communities to increase control over their lives. Communities are groups of people that may or may not be spatially connected, but who share common interests, concerns and identities. These communities could be local, national or international, with specific or broad interests. Empowerment refers to the process by which people gain control over the factors and decisions that shape their lives. It is the process by which they increase their assets and attributes and build capacities to gain access, partners, networks and/or a voice, in order to gain control. Enabling implies that people cannot be empowered by others; they can only empower themselves by acquiring more of power’s different forms . It assumes that people are their own assets, and the role of the external agent is to catalyze, facilitate or accompany the community in acquiring power.

Community empowerment, therefore, is more than the involvement, participation or engagement of communities. It implies community ownership and action that explicitly aims at social and political change. Community empowerment is a process of re-negotiating power in order to gain more control. It recognizes that if some people are going to be empowered, then others will be sharing their existing power and giving some of it up . Power is a central concept in community empowerment. Community empowerment necessarily addresses the social, cultural, political and economic determinants that underpin health, and seeks to build partnerships with other sectors in finding solutions.

In the Community Led Sustainable Health Project Phase II, as they share the common interests and concerns about health issues, communities are defined as people living within the administrative boundaries of the old ward of an union and in case of municipality, half of the old ward for the Community Support Groups. However for the Health Watch Committees people of the entire union and half of the municipality are considered as community. Through the proposed community empowerment process, people are expected to have better control over health aspect of their lives – they will gain control over the factors and decisions (e.g. behaviours and environment causing ill health and access to health care to cure ill-health) affecting their health.

 

3. Rights based approach

Most, if not all, organizations see a “rights-based” or “human rights” approach as a catalyst that can transform the practice of development from a focus on identifying and meeting needs to enabling people to recognize and claim rights that are enshrined in the Universal Declaration of Human Rights (UDHR). For most, too, this entails (1) work with duty-holders – generally state, but also increasingly non-state actors – to strengthen their capacity to respond and be accountable in protecting, respecting and fulfilling human rights: what UK’s Department For International Development (DFID) terms “obligation”, and the UN Office of the United Nations High Commissioner for Human Rights (OHCHR) terms “accountability”; and (2) work to build the capacity of citizens to claim their rights, by working alongside them as advocates and by seeking to provide opportunities for people to empower themselves. The Community Led Sustainable Health Project Phase II also enables people to recognize and claim health rights. The project strategies include work (through the health watch committees) with the duty-holders, both state and non-state, to strengthen their capacity to respond and be accountable in protecting, respecting and fulfilling rights to access to health care of the people and also to build the capacity of the citizens (through health watch committees) to claim their rights of health care.

 

4. Community Empowerment Strategies

Two types of community based organizations (CBOs) will be formed as part of community empowerment strategies: Community Support Groups (CSGs) and Health Watch Committees (HWCs).

4.1 Community Support Groups (CSGs)

As the name implies, CSGs will support the community people to access and utilize the health care services – preventive and curative. Community people face many types of barriers in accessing and utilizing health care services. In case of obstructed and prolong labour, when shifting to health facility is inevitable to save the lives of the mother and baby, the decision makers in the family (in-laws, husband etc.) may not agree to shift (social barrier); the family may not have money to bear the expenses, if shifted to the health facility (economic barrier); transport may not be available, as the incident is in mid-night (physical barrier); after shifting to the facility, blood might be required as caesarean section is planned (treatment barrier). CSGs are expected to handle all these barriers and ensure access and utilization of services for all in the communities.
One CSG is expected to form in the old ward of an union and thus three CSGs per union. Since the municipality is bigger than union, six CSGs are expected to form within the municipality. Thus the project areas will have 33 CSGs in total. Health Motivators (HM) are entrusted for the formation, capacity building and effective functioning of the CSGs. Each HM will be assigned with number of CSGs.

4.1.1 Composition of CSG

Each CSG will be a team of 11 members, who will be from the community for which it is formed. Equal representation from gender, religious belief, socio-economic class, age structure, profession, power structure, disabled, vulnerable and marginalized groups etc. will be taken care as much as possible while forming the CSG, so that it really represents all the segments of the society. While involvement of the power structure is necessary for the effective operation of the CSG, care should be taken so that it doesn’t turn into another elite group and not serving the interests of all, particularly poorest, vulnerable and marginalized.

The following office-bearers will be in each CSG:

Head (Prodhan)                      : 1
Vice Head (Saho Prodhan)     : 1 (of opposite sex of head)
Treasurer (Khoshadhakko)      : 1
Organizer (Sangothak) : 1 (of opposite sex of treasurer)
Members (Sadossho)               : 7 (almost equal number from either sex)

Head, Vice Head, Treasurer and Organizer should have basic literacy – reading and writing Bangla with some knowledge of basic arithmetic. Members may be illiterate, though basic literacy is desired. 

4.1.2 Roles of CSG

  1. CSG will first have to be good group or team to work together. For this, they need to trust, respect and support each other. They need to be very clear about their objective – support all the community members to access and utilize preventive and curative health services to remain healthy and lead economic productive life. They need to internalize that they are to support all of the community members. Thus they should be continuously thriving to reach the invisible – disabled, poorest, vulnerable, marginalized, poorest, women, children etc. They should be allocating roles and responsibilities among themselves in a way that best suitable person is entrusted with the responsibilities best done by him/her. Ideally they should demarcate the entire community into 11 and assign each area to one of them, so that they can closely keep vigilance over the community members within their allocation.

 

  1. They should meet regularly. Once in a month is mandatory. More frequent in the initial days is required for forming as group, understand and build their capacities to discharge desired roles.
  1. Each of their meetings must have simple majority to form quorum and all the meetings need to be properly minuted, especially the decisions should recorded and followed-up in subsequent meetings.

 

  1.  Each of them should inform their respective community members about  locations, schedules (day and time), types of services available with charge (if any) both from government and non-governmental sources and encourage them to utilize services as early as possible, when required.
  1. Each of them should be well conversant about the need of services by the community people of their jurisdiction and preferably keep a list of so to monitor utilization. For example, they should know about the birth of the baby of their respective areas and then monitor timely immunization uptake. Similarly they should enquire and record pregnant women and follow them for antenatal care, birth planning and safe delivery.

 

  1. Each of them should keep proper vigilance in their respective areas, so that they can support the required community member to access and utilize required services by removing the barrier that obstructs in service access and utilization.
  1. Each CSG will set up a solidarity fund from the contributions of the community people according to their ability to pay. They will also formulate guidelines for its formation and operation and make those known to the community people. They will periodically publish books of accounts of the solidarity fund to the community people. This solidarity fund will support needed community member to overcome economic barrier in accessing and utilizing care. For example, if a pregnant required hospitalization for caesarean section, individual family savings may not be adequate to withstand, but loan (with or without interest) from the solidarity fund may support to utilize the services. In principles, catastrophic illness (like accidents – fall from tree, road-traffic accidents, violence, trauma, major diseases etc.) where individual families are unable to withstand can be supported from the solidarity fund.  

 

  1. CSG may invest in transportation (rikshaw van, boat etc.) from solidarity fund, if feasible. The bought transport is then put on hire, which will ensure expansion of fund by adding income from rent. But the same transport can be used in case of emergency for the transportation of patient to save life.
  1. CSG may initiate programme to have all the community members know their blood groups and issue card accordingly after proper grouping. In case of apprehended blood requirements, such as pregnant for caesarean section or road-traffic accident with lot of blood loss etc. persons of same blood group of the pregnant or accident victim may accompany in the hospital and donate blood in case of need without delay to save life.

 

  1. CSG will keep proper liaison with the respective Health Watch Committee and Health Promotional Groups and they will distribute such responsibilities among themselves for proper compliance.   

4.1.3 Individual roles of the CSG members

Head (Prodhan)

  1. Convene the CSG meeting, preferably in consultation with all others, so that attendants of maximum, if not all, can be ensured
  2. Preside the CSG meetings
  3. Record attendants and minutes of the CSG meetings with decisions made
  4. Ensure decisions of previous meetings are adequately followed-up in the subsequent meetings, so long those remain valid
  5. Keep liaison with the respective HWC
  6. Inform community members of the assigned area about locations, schedules (day and time), types of services available with charge (if any) both from government and non-governmental sources and encourage them to utilize services as early as possible, when required.
  7. Keep vigilance, make record and undertake proper follow up for access and utilization of services by the respective community members
  8. Support required community members to overcome the barriers to access and utilize required services

 

Vice Head (Saho Prodhan)

  1. Attend CSG meetings regularly
  2. In absence of Head (Prodhan), convene the CSG meeting, preferably in consultation with all others, so that attendants of maximum, if not all, can be ensured
  3. In absence of Head (Prodhan), preside the CSG meetings
  4. In absence of Head (Prodhan), record attendants and minutes of the CSG meetings with decisions made
  5. In absence of Head (Prodhan), ensure decisions of previous meetings are adequately followed-up in the subsequent meetings, so long those remain valid
  6. In absence of Head (Prodhan), keep liaison with the respective HWC
  7. Inform community members of the assigned area about locations, schedules (day and time), types of services available with charge (if any) both from government and non-governmental sources and encourage them to utilize services as early as possible, when required.
  8. Keep vigilance, make record and undertake proper follow up for access and utilization of services by the respective community members
  9. Support required community members to overcome the barriers to access and utilize required services

 

Treasurer (Khoshadhakko)

  1. Attend CSG meetings regularly
  2. Setting up and operational of the solidarity fund including preparing guidelines and making those known to the community people, after approval of the CSG; collecting contributions; disbursement of funds; collection of payment of disbursed fund; periodic publish of book of accounts of solidarity fund to the community people; management of investment from the solidarity fund, as approved in the CSG (like transportation etc.) etc.
  3. Inform community members of the assigned area about locations, schedules (day and time), types of services available with charge (if any) both from government and non-governmental sources and encourage them to utilize services as early as possible, when required.
  4. Keep vigilance, make record and undertake proper follow up for access and utilization of services by the respective community members
  5. Support required community members to overcome the barriers to access and utilize required services

 

Organizer (Sangothak)

  1. Attend CSG meetings regularly
  2. Organize the blood grouping of the community members and provide each of them with a card mentioning respective blood group; keep a record of blood groups of all the community members, coordinate blood donations in required cases.
  3. Inform community members of the assigned area about locations, schedules (day and time), types of services available with charge (if any) both from government and non-governmental sources and encourage them to utilize services as early as possible, when required.
  4. Keep vigilance, make record and undertake proper follow up for access and utilization of services by the respective community members
  5. Support required community members to overcome the barriers to access and utilize required services

 

Members (Sadossho)

  1. Attend CSG meetings regularly
  2. Inform community members of the assigned area about locations, schedules (day and time), types of services available with charge (if any) both from government and non-governmental sources and encourage them to utilize services as early as possible, when required.
  3. Keep vigilance, make record and undertake proper follow up for access and utilization of services by the respective community members
  4. Support required community members to overcome the barriers to access and utilize required services

 

4.1.4 Support required to the CSG

  1. While forming the CSG, representation from all segments of the community (sex, age, socio-economic, power structure, disable etc.), willingness to work for CSG by devoting time and energy, literacy level required etc. need to adhere strictly. Any compromise might back-fire in the effectiveness of the CSG

 

  1. After formation of the CSG, all the CSG members must undergo capacity building training, in which each of them have to be very clear about their own roles with their collective roles and objectives thereof. In fact each of them should be supplied with aim of the CSG, roles of the CSG and respective individual role written in Bangla.
  1. Each of them will be supplied with the information about locations, schedules (day and time), types of services available with charge (if any) both from government and non-governmental sources of their respective assigned area, so that they can disseminate the same among the respective community members and encourage them to access and utilize those services.

 

  1. Each of them will also be oriented about the possible services to be utilized by the respective community people, so that they can record the same and undertake monitoring to ascertain proper access and utilization. For example, recording the birth of the baby, they can monitor immunization uptake of the respective babies; recording the pregnancy, they can monitor utilization of required antenatal care, birth planning, safe delivery etc.
  1. Each of them will be thoroughly oriented about the possible types of barriers (social, economic, physical, transport, blood etc.), so that they keep vigilance and support the respective community member to overcome the barrier faced to ensure access and utilization

 

  1. Head and Vice Head should be thoroughly oriented to acquire necessary skills of convening, conducting, and recording meetings and also representation particularly with the HWC. They should also be provided with required logistics like meeting attendance register, minutes book, pen, paper etc.
  1. Treasurer should be thoroughly oriented for setting up and operational of the solidarity fund including preparing guidelines and making those known to the community people, collecting contributions; disbursement of funds; collection of payment of disbursed fund; periodic publish of book of accounts of solidarity fund to the community people; management of investment from the solidarity fund (like transportation etc.) etc.

 

  1. Organizer should be thoroughly oriented for organizing the blood grouping of the community members and provide each of them with a card mentioning respective blood group; keep a record of blood groups of all the community members, coordinate blood donations in required cases.
  1. Cross visit for better understanding of solidarity fund and blood grouping organization within the country, where it is matured now may be effective for capacity building in respective areas.

 

  1. HMs should hand hold CSGs in its formation and operation in initial days, and then gradually taking back seat while still observing to provide the back stopping support required. As the time passes CSGs should be operational of its own, with periodic supervision by the HMs. 

Labonte R. and Laverack G. (2008) Health promotion in action: from local to global empowerment

Baum, F. (2008) Foreword to Health promotion in action: from local to global empowerment

4.2 Health Watch Committees (HWCs)

HWC aims to ensure availabilities of services both from government and non-government sources for the communities, so that they can access and utilize the same in case of need and thus remain healthy and lead an economic productive life. Bangladesh has one of the best public health infrastructures in South Asia. But due to lack of governance most of it remain non-functional and people remain deprived from the required services. HWC, as community based organization, intends to keep vigilance over the designated government and non-governmental services intended for the community and through negotiating with the designated service providers and their supervisors (in case of need) attempts for proper functioning of the same.

One HWC intends to operate in each union. Since the municipality is larger than the union, two HWCs are planned for the municipality. Thus 11 HWCs are planned to set up and operate in the project areas. The Programme Organizer (PO) is entrusted for the formation, capacity building and effective operational of the HWC. Each PO is assigned to a number of HWCs.  

4.2.1 Composition of HWC

HWCs are of 11 member team. They will be drawn from various segments of the communities of the union or parts of the municipality for which it will be formed. It should represent different sex, age, religion, disability, profession, union parisad/ municipality, socio-economic group, marginalized, vulnerable etc.  While involvement of the power structure is necessary for the effective operation of the HWC, care should be taken so that it doesn’t turn into another elite group and not serving the interests of all, particularly poorest, vulnerable and marginalized.

The following office-bearers will be in each HWC:

Head (Prodhan)                      : 1
Vice Head (Saho Prodhan)     : 1 (of opposite sex of head)
Organizer (Sangothak) : 1
Members (Sadossho)               : 8 (almost equal number from either sex)

Head, Vice Head and Organizer should have basic literacy – reading and writing Bangla with some knowledge of basic arithmetic. Members may be illiterate, though basic literacy is desired. 

4.2.2 Roles of HWC

  1. HWC will first have to be good group or team to work together. For this, they need to trust, respect and support each other. They need to be very clear about their objective – ensure availabilities of services both from government and non-government sources for the communities, so that they can access and utilize the same in case of need and thus remain healthy and lead an economic productive life. They need to internalize that they are to make all service delivery points functional and not of only at higher level, which may be utilized by most of them. Service delivery at lower levels might serve the purpose of poorest, women, children, vulnerable and children. They should be allocating roles and responsibilities among themselves in a way that best suitable person is entrusted with the responsibilities best done by him/her. Ideally they should demarcate the entire union/part of the municipality into 11 and assign each area to one of them, so that they can closely keep vigilance over the service delivery points within their allocation.

 

  1. They should meet regularly. Once in a month is mandatory. More frequent in the initial days is required for forming as group, understand and build their capacities to discharge desired roles.
  1. Each of their meetings must have simple majority to form quorum and all the meetings need to be properly minuted, especially the decisions should recorded and followed-up in subsequent meetings.

 

  1. Each of them must record the health service delivery points under his/her jurisdiction. S/he needs to be familiarized with the service delivery points – schedule of operation (opening days and duration), types of services available, number and types of service providers, fees schedule (if any) etc. S/he will monitor the service delivery points and discuss with the service providers, if deviations found. If deviation continues or beyond the jurisdiction of the respective service providers, then the issue needs to be raised in the HWC meetings, which will then take up the matter with the supervisors of the concerned service delivery points.
  1. If HWC fails to bring the issue in order after bringing the same in the notice of the supervisors of the service delivery points, then they should write the matter to the district authority and inform the press. They need to continue this informing district authority and publishing by press repeatedly until the issue is resolved.

 

  1. HWC should liaison with the Union Parisad Standing Committee on Health, Family Planning and Epidemic Control, whose mandate includes vigilance over local health service delivery points (both government and non-government). If necessary, HWC should facilitate formation and activation of such committee and work with it, as that is mandated to do the same as aimed by the HWC.
  1. HWC should liaison with the Upazila Health Complex Advisory Committee, formed by the Ministry of Health and Family Welfare and whose mandate includes monitoring activities of upazila level hospitals including upazila health complex. If required, HWC should facilitate formation and activation of such committee and work with it, as that is mandated to do same as aimed by the HWC.

 

  1. HWC should liaison with the local journalists and continuously feed them with prevailing situation so that they publish the same to bring to the notice of the higher authorities.    
  1. HWC may ensure proper maintenance and operation of the water points and toilet facilities established for public usages like those of schools, market places etc. 

 

4.2.3 Individual roles of the HWC members

Head (Prodhan)

  1. Convene the HWC meeting, preferably in consultation with all others, so that attendants of maximum, if not all, can be ensured
  2. Preside the HWC meetings
  3. Record attendants and minutes of the HWC meetings with decisions made
  4. Ensure decisions of previous meetings are adequately followed-up in the subsequent meetings, so long those remain valid
  5. Keep liaison with the supervisory authorities of the service delivery points
  6. Inform the decision of the HWC meetings regarding deviations in the service delivery points to the respective supervisors, district authorities, press, as the case may be.
  7. Record the service delivery points under his/her assigned areas. S/he needs to be familiarized with the service delivery points – schedule of operation (opening days and duration), types of services available, number and types of service providers, fees schedule (if any) etc. S/he will monitor the service delivery points and discuss with the service providers, if deviations found. If deviation continues or beyond the jurisdiction of the respective service providers, then the issue needs to be raised in the HWC meetings.

 

Vice Head (Saho Prodhan)

  1. Attend HWC meetings regularly
  2. In absence of Head (Prodhan), convene the HWC meeting, preferably in consultation with all others, so that attendants of maximum, if not all, can be ensured
  3. In absence of Head (Prodhan), preside the HWC meetings
  4. In absence of Head (Prodhan), record attendants and minutes of the HWC meetings with decisions made
  5. In absence of Head (Prodhan), ensure decisions of previous meetings are adequately followed-up in the subsequent meetings, so long those remain valid
  6. In absence of Head (Prodhan), keep liaison with the supervisory authorities
  7. In absence of Head (Prodhan), inform the decision of the HWC meetings regarding deviations in the service delivery points to the respective supervisors, district authorities, press as the case may be.
  8. Keep liaison with the Upazila Health Complex Advisory Committee on behalf of the HWC
  9. Record the service delivery points under his/her assigned areas. S/he needs to be familiarized with the service delivery points – schedule of operation (opening days and duration), types of services available, number and types of service providers, fees schedule (if any) etc. S/he will monitor the service delivery points and discuss with the service providers, if deviations found. If deviation continues or beyond the jurisdiction of the respective service providers, then the issue needs to be raised in the HWC meetings.

 

Organizer (Sangothak)

  1. Attend CSG meetings regularly
  2. Keep liaison with the Union Parisad Standing Committee on Health, Family Planning and Epidemic Control on behalf of the HWC
  3. Record the service delivery points under his/her assigned areas. S/he needs to be familiarized with the service delivery points – schedule of operation (opening days and duration), types of services available, number and types of service providers, fees schedule (if any) etc. S/he will monitor the service delivery points and discuss with the service providers, if deviations found. If deviation continues or beyond the jurisdiction of the respective service providers, then the issue needs to be raised in the HWC meetings.

 

Members (Sadossho)

  1. Attend CSG meetings regularly
  2. Record the service delivery points under his/her assigned areas. S/he needs to be familiarized with the service delivery points – schedule of operation (opening days and duration), types of services available, number and types of service providers, fees schedule (if any) etc. S/he will monitor the service delivery points and discuss with the service providers, if deviations found. If deviation continues or beyond the jurisdiction of the respective service providers, then the issue needs to be raised in the HWC meetings.

4.2.4. Support required to the HWC

  1. While forming the HWC, representation from all segments of the community (sex, age, socio-economic, power structure, disable etc.), willingness to work for HWC by devoting time and energy, literacy level required etc. need to adhere strictly. Any compromise might back-fire in the effectiveness of the HWC

 

  1. After formation of the HWC, all the HWC members must undergo capacity building training, in which each of them have to be very clear about their own roles with their collective roles and objectives thereof. In fact each of them should be supplied with aim of the HWC, roles of the HWC and respective individual role written in Bangla.
  1. Each of them will be supplied with the information about locations, schedules (day and time), types of services available with charge (if any) both from government and non-governmental sources of their respective assigned area, so that they can record the same and monitor for deviations, if any.

 

  1. Each of them will also be supplied with the list of water points and toilet facilities established for public usages like those in schools, market places together with the information of the authorities responsible for maintaining those.
  1. Each of them will also be oriented about the line of supervision of the respective service delivery points.

 

  1.  Head and Vice Head should be thoroughly oriented to acquire necessary skills of convening, conducting, and recording meetings and also representation particularly with the supervisory and district authorities of the service delivery points. They should also be provided with required logistics like meeting attendance register, minutes book, pen, paper, envelope etc.
  1. Vice Head and Organizer should be thoroughly oriented on Upazila Health Complex Advisory Committee and Union Parisad Standing Committee on Health, Family Planning and Epidemic Control respectively. They need to be supported for the formation and activation of the respective committees, if required.

 

  1. Cross visit for better understanding of HWC within the country, where it is matured now may be effective for capacity building in respective areas.
  1. POs should hand hold HWCs in its formation and operation in initial days, and then gradually taking back seat while still observing to provide the back stopping support required. As the time passes HWCs should be operational of its own, with periodic supervision by the POs. 

 

Conclusion

With the proper formation and effective functioning of the CSGs and HWCs in the project areas, availability of services from both governmental and non-governmental sources are expected to improve substantially, which will also be accessed and utilized by all segments of the community through the support of the CSGs in due time, so that their health status improves substantially and support them in leading an economic productive lives. Since both the CBOs comprise of local community people, they are expected to remain functional beyond the project life, thus ensuring sustainability of the achievements. 

 

 

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Quarterly Programme Meeting 19-21 July 2011