Combining health and social protection measures to reach the ultra ...

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Decision-makingGenerally, any research question can apply and employparticipatory approaches. In the Tanzania Essential HealthInterventions Project (TEHIP), the Community VoiceComponent employed Participatory Action Research (PAR) intrying to answer the question, “How can communities beeffectively involved in district health planning processes?”.The initial objective was to develop a procedural frameworkfor incorporating Community’s Voice into District HealthPlans 5 . Traditionally, stern professionals with a soundbackground in participatory methods and communityinvolvement would have been contracted to develop such aframework. However, by using a participatory action researchapproach, communities in selected study districtssignificantly contributed to the design of such a framework(planning tool). The result was the availability of a practicaltool that took into account the views of both professionals andthe community.What can participatory health researchachieve?Like in any other type of research model, the key product ofcommunity participation and involvement is data. Datagenerated through a participatory process normally producesricher information than that from a classical data set. Theform in which the data is normally made available is clearerand easier to be understood by all those involved in theresearch process – as well as by those who were not – thanare classical data sets from surveys.Apart from the data, an additional value of a participatoryhealth research process is the interaction that happensbetween the outsiders and the communities. This interactionis very important for understanding social factors, suchas how people understand disease, that may influencepeople’s health-seeking behaviours and patterns of healthcare use 4 . In a later stage, this understanding is importantin designing health services that reflect people’s culture anduse local knowledge, which in turn has been shownto increase acceptability of the services, compared to servicesthat do not take these into account. Even where healthinfrastructures are available, providing information in one’sown language, ensuring culturally appropriate careor supporting community networks for prevention and followupof illness, are all important factors in improving accessto care. Research processes that have involved peopleas active participants have brought about these effectsand impacts.There are three main levels of impacts on the community,from which we can deduce what community involvement inhealth research can achieve. Each level has a different scope,but each is equally important:1. The immediate impacts and direct benefits for individualsand families.2. The broader impact on “social capital” or localorganizations, namely the empowerment andrepresentation of communities and their members.3. The overall impact on local society.At each level, the forms of expected impacts may also vary.Impacts may have material, human and spiritual attributes.These are seen across a continuum of tangible and intangibleimpacts, including environmental, productive, and physicalchanges, as well as overall transformations at the individualand community level. Tangible impacts are changes that canbe observed directly, and measured and documented quickly.Intangible impacts are more subtle, internal or attitudinalchanges that can also be documented but often in a more“qualitative” manner 6 .Can participatory health researchapproaches achieve everything?Participatory approaches that involve communities arebasically reflective and are primarily qualitative in nature.People who are used to drawing conclusions using numbersand figures might be a bit disappointed, although evenquantitative information can be gathered throughparticipatory methods. Tools used in participatory researchare designed to gather people’s knowledge generated fromtheir own opinions and experiences. By definition, much ofthis knowledge is not measurable in the scientific sense of theword but, nevertheless, vital if communities and outsiders areto work successfully together in improving the health andwell-being of individuals, communities and the nation.At the same time, this does not mean participatoryresearch and action ignores quantitative data i.e. data that iscounted or measured. There are examples of participatorymethods for research in health that provide evidence that isquantitative. We can use participatory methods in healthresearch to produce averages and other quantitativeinformation 4 .Who should be involved when communityparticipation in health research is applied?Beyond the immediate networks of households and families,there are social groupings within “communities”. These socialgroups share a common experience or situation. For examplethey share the same social class, income level, gender,geographical area, age, ethnic or religious group, politicalstatus or other social and economic factors or experiences.These factors and experiences can influence how healthythey are, how they are able to create and sustain their ownhealth, how they are exposed to disease, and how much theyare affected by ill health. It can also influence how well theyare served by health or other community services that affecttheir health, or how they access those services. For example,disabled people as a social group face particular difficulties inachieving the conditions needed to create and sustain theirhealth. They are often subject to stigma, discrimination, andsocial marginalization and exclusion that prevent them fromparticipation in the lives of their families and communities,schools, workplaces and income-generating activities andfrom benefiting from the results of that participation. Often,their health needs are not recognized and they mayexperience exclusionary criteria from medical and othercommunity services necessary to their health. In addition,access to health services is often made difficult or impossiblebecause of architectural barriers, lack of accessible transportand inappropriately planned and designed health services.178 ✜ Global Forum Update on Research for Health Volume 4
Decision-makingSeveral strategies are needed for each of the identifiedsocial groups we have identified to build interest and becomeactively involved in health activities. One of the first of theseis for people to be aware. Information is power. Thecommunity that is well informed about the existing healthactivities stands a better chance to raise their voice, debateand demand inclusion, participation and social justice. Wethus need to include in the design of any programme,components that provide for awareness creation, for listeningto inputs from communities and feeding information back tocommunities.It is practically impossible to involve everybody throughoutall stages of implementation of a health research, programmeor activity. Different stages of the programme will involvedifferent people in the community. For example, during theintroduction, awareness creation and sensitization of thehealth activity, all community members would preferably beinvolved. However, at a stage such as planning,representation is important as it is not possible to have all thecommunity members in a planning meeting. Representationis more easily achieved if we know the different groups thatneed to be represented and ensure that their interests are alladdressed.It is important when we talk of participatory research inhealth to look beyond community involvement. If for exampleour research is to influence the policy-making process, it isvery essential to identify other partners of the process andinvolve them in earlier stages of the research process ratherthan waiting to involve them at results dissemination andprogramme design. This would include policy-makers, themedia and other key stakeholders.Policy development is complicated and involves a numberof players with diverse interests. Policy interests at local levelmay differ from those at global level. Take for examplemedicines. At the community level, the interest is to makesure that when people fall ill, that they have medicines at thenearest health facility. At the district level, decision-makersmay balance the priorities for drugs for treatment againstspending on prevention, water supplies, improving antenatalservices and so on. At national level there may be issuesabout how much foreign currency is spent on drugs versusfuel and other essential goods. At the global level, theremay be trade rules to do with protecting patents forlarge companies that may limit the options of what countriescan do 4 .Therefore, for communities to effectively work with, engageor influence institutions at different levels it is necessary tounderstand how these institutions are organized, their roles,how information flows between them, and who theirauthorities are. If possible, a research process that intends toengage communities, should also consider other partnersfrom the public departmental sectors, NGOs and CivilSocieties with shared values and interests in the areabeing researched.In summaryCommunity involvement in health research is aboutfacilitating change. If it is used as it should be used, it canlead to major shifts in the way people and organizations thinkand act. When using participatory approaches, practitionersare encouraged to move away from the concept of “them” and“us” to recognizing that health “belongs to us all”. Theattitude and behaviours of the practitioner is central – listento people’s own knowledge, create dialogue, involve peopleand institutions at all levels in decisions and activities.Everybody can learn and acquire “knowledge of”participatory methods but not everybody has the skills toimplement them. Participatory skills are not “acquired bylearning” but rather “by doing after having learned”. Thismakes community participation an area where skills growthrough practice and through getting feedback fromcolleagues and communities.Health research applying a community participationapproach uses a diversity of methods that is limited only byour own imaginations, which are limitless. The methods areflexible and can be adapted to different circumstances.Participatory methods are very strong tools for generatingqualitative data; however, some methods can also generatequantitative data. Participants with guidance from facilitatorscan do their analysis in the field, producing results quicklyand discussing and moving ahead with actions. This is costeffective and results/reports are produced and shared in atimely fashion.Involving communities in health research can be timeconsuming, but can often be done with local resources andmay not be costly. They are not like “quick and dirty surveys”.They need significant listening skills. Some issues may callfor several rounds of reflection, action and then analysis andreflection leading to further action.Approaches that empower people and lead to change maybe threatening to some groups or interests in communities,and change may be resisted. There may be opposition andresistance to participatory research for these reasons. Likeany other method, participatory methods are also open toabuse, and can be used in the wrong way for the wrongreasons. Not every method can work everywhere 4 . ❏Selemani S Mbuyita works as a research officer for IfakaraHealth Research and Development Centre (IHRDC). His work ismainly focused on improving health systems through health systemresearch. He has been working on a number of studies rangingfrom behavioural studies to social equity and governance (usinghealth as an entry point). He had also been involved in somenational studies such as Appraisal of Referral Hospitals in Tanzaniawith the Ministry of Health (Tanzania) and Health PartnersInternational (UK) as the National Social Consultant, as a socialresearch scientist in the Tanzania Essential Health InterventionsProject with the Ministry of Health and IHRDC and as a HealthSocial Consultant in Evaluation of Cost of Chronic Illnesses in theSouthern part of Tanzania with Save the Children (UK) and IHRDC.Currently he is working as a lead implementer on pilotingimplementation of the new malaria drug policy in Tanzania andalso as a lead implementer on piloting community-basedinterventions towards addressing maternal and neonatalmortalities in Tanzania under the EMPOWER project.Global Forum Update on Research for Health Volume 4 ✜ 179
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Contents096 Child immunization: acc
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IntroductionResearch contributions
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IntroductionType IType IIType IIIPr
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Introductionmaking), takes account
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Access to healthStrengthening healt
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Access to healthimperative for acti
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Access to healthReferences1.Further
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Access to healthDeterminantsAvailab
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Access to healthThe authors are inv
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Access to healthCombining health an
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Access to health100%Availability of
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Access to healthReferences continue
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Access to healthintegrating individ
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Access to healthA social determinan
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Access to healthemployment conditio
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Access to healthMaking human rights
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Access to healthResources outsideth
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Access to healthReferences1.McCoy D
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Access to healthand financial burde
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Access to healthDiscrimination as a
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Access to health“Two months ago I
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InnovationTowards the development o
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Innovation60% of enterprises5040302
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InnovationFinancing of vaccine R&D-
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InnovationChild immunization:accele
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InnovationDeveloping countries % De
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Innovationcapacities. It is indeed
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InnovationSome plausible causes of
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Research resourcesResearch impact o
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Research resources1,61001,41,219080
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Research resourcesThe threat of pan
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