Community involvement in health policy; Socio-structural and dynamic aspects of health beliefs

The notion of community involvement in health, as in fact in schemes of community welfare generally, has found wide acceptance in all kinds of political regimes and particularly in the Third World countries. Such involvement is expected not only to be cost-effective but, more importantly, the best way of providing comprehensive solutions to public health problems. More than 50 years of experience with schemes of community participation in India, however, show that the enthusiasm of the people generally tends to wane after a short period of time. Nevertheless, efforts at community involvement in health continue to be made. Governmental and non-governmental organizations and UN agencies, notably WHO, have been active in promoting the concept. The 1978 Alma Ata declaration on primary health care strongly emphasized the right and duty of people to plan and implement health care programmes. Even so, many operational problems remain and these are perhaps related partly to a lack of conceptual clarity. Ideally, community involvement should mean that the initiatives come from the people and the government and other agencies provide assistance. In reality, however, this rarely is so. The best that may be expected is that people will come forward voluntarily to participate in public health programmes. Generally, however, their co-operation has to be sought and they have to be motivated to participate in health schemes. Involvement could also be brought about through coercive measures but there is little support for such an approach, though many health programmes (such as that of small pox vaccination) have been known to have depended upon compliance for their success. Community participation is often hampered by a wide range of factors including a difficult terrain where the community lives, inegalitarian social structure, the tendency to depend upon others to look after one's needs, and the absence of an understanding of such ideas as safe drinking water, health and illness which coincides with that of health workers. Bureaucrats and medical professionals also are known not to particularly favour community involvement as they consider this to be an interference. Such difficulties notwithstanding, governments, voluntary organizations and committed individuals are everywhere engaged in experiments to devise the best means of community participation in health. In this regard, certain state-sponsored schemes and individually organized projects in India have provided many valuable insights which may be of use in other developing countries also.