Research Article Community participation in primary health care projects of the Muldersdrift Health and Development Programme

M Barker Master student, Department of Nursing Education, University of the Witwatersrand, H Klopper Professor, School of Nursing Science, North-West University, South Africa

Abstract: Curationis 30(2): 36-47 After numerous teething problems (1974-1994), the Department of Nursing Education of WITS University took responsibility for the Muldersdrift Health and Development Programme (MHDP). The nursing science students explored and implemented an empowerment approach to community participation. The students worked with MHDP health workers to improve health through community participation, in combination with primary health care (PHC) activities and the involvement of a variety of community groups. As the PHC projects evolved overtime, the need arose to evaluate the level of community participation and how much community ownership was present over decision-making and resources. This led to the question “What was the level of community participation in PHC projects of the MHDP?” Based on the question the following objectives were set, i.e. i) to evaluate the community participation in PHC initiatives; ii) to provide the project partners with motivational affirmation on the level of community participation criteria thus far achieved; iii) to indicate to participants the mechanisms that should still be implemented if they wanted to advance to higher levels of community participation; iv) to evaluate the MHDP’s implementation of a people-centred approach to community participation in PHC; and v) the evaluation of the level of community participation in PHC projects in the MHDP. An evaluative, descriptive, contextual and quantitative research design was used. Ethical standards were adhered to throughout the study. The MHDP had a study population of twenty- three (N=23) PHC projects. A purposive sample of seven PHC initiatives was chosen according to specific selection criteria and evaluated according to the “Criteria to evaluate community participation in PHC projects” instrument (a quantitative tool). Structured group interviews were done with PHC projects’ executive committee members. The Joint Management Committee’s data was collected through mailed self­ administered questionnaires. Validity and reliability were ensured according to strict criteria. Thereafter results were analysed and plotted on a radiating arm continuum. The following factors had component scores: organization, leadership, resources, management; needs and skills. A spider graph was produced after each factor’s Correspondence address: continuum was connected in a spoke figuration that brought them together at the Prof Hester Klopper base where participation was at its most narrow. The results are presented and a graph Private Bag X 6001 an(j discussion is provided on each o f the PHC projects. School of Nursing Science North-West University ( researc[1 resuits indicated that although community participation was broadened, Campus) there was minimal success in forcing a shift in power over decision-making and Potchefstroom, 2520 resources. This demonstrated that power over planning and resources should remain Tel: (018) 299-1829/1830 in the hands of the partners if community participation was to remain progressive and Fax: (018)299 1827 sustained. Results furthermore indicated that the people-centred approach to E-mail: [email protected] community participation enabled participants to broaden community participation. 36 Curationis June 2007 With regard to the Joint Management medicine and identified four approaches students took over the MHDP at the end Committee’s evaluation of community to community participation in PHC. of 1995 that the ‘people-centred’ or participation, it was concluded that Rifkin and Cassels (1990:39) summarised empowerment approach to community power over decision-making and the community’s role in each of these four participation was fully explored and resources remained with health approaches to community participation implemented in 1996. In this approach professionals rather than with the as; compliance in the public health the root causes of health problems are community, and that a people-centred approach; contribution in the health seen as being mainly political as the need approach had not been adopted. planning approach; control in the self- ‘to empower’ people acknowledges that care approach, and lastly collaboration their low status has resulted from with eventual control of activities and continued oppression by society Background to the resources by the community in the (Wallerstein, 1992inMokwena, 1997:67). problem community development approach. One Swanepoel (1997:7) stated that The University of the Witwatersrand’s of Rifkin’s (1981:377-386) identified empowerment means the acquisition of (WITS) Muldersdrift Health and approaches i.e. the community power and the ability to give it effect and Development Programme (MHDP) was development approach evolved into the it manifests in groups of people working initiated in 1974 by a group of concerned radical participatory approach, which together. Community participation is medical students who responded to the gained prominence and further seen as a way of ensuring equity with health needs of a deprived community, developed into even more variants, one the poorest of the poor having the living in a peri-urban area on the north­ of which is the empowerment or ‘people- democratic right to participate in western outskirts of , called centred approach’. The MHDP’s decisions affecting his/her development Muldersdrift. Unfortunately the student Constitution was revised and Clause 3 [health] (Gran, 1983:2; also compare driven programme faltered in 1996 due to stated that the ‘people-centred approach’ Barker, 2003:5). The people-centred/ lack of donor funding and commitment. to development was chosen to guide the empowerment approach to community While alternative arrangements were programme partners (University of the participation is described in Korten’s being investigated, the Department of Witwatersrand, 1984:2). (1990:67) definition of development as; Nursing Education took over the “... a process by which the members of a administration of the programme from The history of the MHDP indicates that society increase their potential and 1995 to 1999. A partnership was the medical students were not very institutional capacities to mobilise and negotiated between the successful in implemention of a ‘people- manage resources to produce Department of Health’s centred approach.’ That the medical sustainable and justly distributed Regional Office (WRRO), the University students debated Rifkin’s (1981) various improvements in their quality of life [or of the Witwatersrand (WITS) and the approaches to community participation their health in the PHC context] Muldersdrift Community through the in PHC can be identified in the consistent with their own aspirations”. Muldersdrift Clinic Committee (MCC). A immunisation drives and the pit toilet This definition implies that the Joint Management Committee (JMC), building projects in 1988 and 1989 (public community should have the power and with four representatives each from these health approach). The health planning that this power be directed to ensuring three partners, was formed. This approach is identified in the employment an equitable share of the health provided an ideal opportunity for an and training of community members as resources. evaluation of the participation of the family planning motivators, community community and specifically the MHDP. development officers and community Within this approach the MHDP health health workers (CHWs). The health care providers had to change from the Rifkin, Muller and Bichmann (1988:933) planning approach is also identified in ‘top-down’ approach to decision-making, clarified the community participation the decision-making process. The where a change agent stimulated process in the context of Primary Health medical students had initiated and community participation, to a ‘bottom- Care (PHC), defined the concept elected the Muldersdrift Clinic Health up’ approach where the community ‘community’ and also hinted at the power Committee through which they sought acquired the power and drove the shifts (empowerment) required for community advice and taught the planning process. The MHDP with the development. They stated: “Community community participants, through a involvement of the nursing science participation is a social process whereby dialogue, but ultimately they retained the students became what Korten (1990:498) specific groups with shared needs living power over decision-making. As Gaede, called an adaptive organisation, which in a defined geographic area actively (1994:49) reports: “In 1989, a number of he described as organisations “...with a pursue identification of their needs, take projects with participation from the well-developed capacity for responsive decisions and establish mechanisms to community members, were initiated. and anticipatory adaptation - meet these needs. In the context of PHC, Attempts were made to run creches, organisations that: (sic) (a) embrace error; this process is one which focuses on the parents meetings, women’s groups and (b) plan with the people; and (c) link ability of these groups to improve their income generating groups. Food gardens knowledge building with action.” The health care and by exercising effective and first aid training were tried. But none MHDP health care providers had to decisions to force the shift in resources of the projects lasted longer than 6 to 8 change their role to that of an enabling with a view to achieving equity.” months. The majority failed because the partner in the community participation control and maintenance of the projects process. The intensity of this Rifkin (1981:377-386) traced the power was entirely dependent on the students.” enablement required adaptation to suit shifts that occur with the involvement of each PHC project’s level of community laymen in the specialised field of It wasn’t until the nursing science participation. The MHDP health workers 37 Curationis June 2007 agreed with Rifkin, et al, (1988) and took these ranking criteria and applied them • The Rietfontein Village as their starting point that health theoretically to a number of PHC projects Association’s ‘Water Project’. improves through community and found the criteria too broad, • The Ladies Income-generating participation and that broad participation subjective, conflicting and neglectful of ‘Sewing and Crochet Project’. builds on a wide range of PHC activities important details relating to the process • The Lesedi Youth Association’s and the involvement of many different of participation, which led to difficulties Income-generating ‘Basket community groups. in interpretation. They took up the Weaving Project’. challenge to expand Rifkin’s, et al, (1988) Each PHC initiative’s level of The Muldersdrift community, at an open work to develop criteria, for evaluation, •community participation will well advertised meeting in 1996, elected which could be adapted to local South also serve as baseline data for the Muldersdrift Clinic Committee (MCC) African conditions. They agreed with the JMC; the WRRO health care with 28 representatives. Each PHC project Rifkin, et al, (1988) on the dual value of workers; the MCC and the elected a representative thus ensuring the indicators. various project members participation of the youth, the senior against which future citizens, women and men’s groups. evaluations of the same Representatives from each geographical Research problem A plethora of PHC projects had projects could be measured. area covered by the MHDP and five evolvement from the community members 2. To provide the project partners community leaders were also elected. involved in the MHDP from 1992, but with motivational affirmation on The MCC later elected four there was a lack of information on the the level of community representatives to represent them on the exclusivity of the community participation criteria thus far Joint Management Committee (JMC). participation, as well as a lack of achieved. The majority of the PHC projects were information on how much community 3. To indicate to the participants initiated in partnership with the MCC. ownership there was over decision­ the mechanisms that should still Unfortunately this body was disbanded making and resources. Thus at the start be implemented (criteria still to late in 2000. of the Joint Management Committee’s era be achieved) if they are to of management, the problem was a lack advance to higher levels of As the PHC projects evolved over time, of data on the level of community evaluation of the level of community community participation on participation within the MHDP. This their own community health and participation achieved, by the problem leads to the research question participants in each PHC project, became development pathway. that the research study sought to answer: 4. To evaluate the MHDP’s necessary to guide the intensity of “What was the level of community implementation of people- enablement required for each project. participation in Primary Health Care centred approach to community Rifkin, et al, (1988:931 -940) recognised projects of the Muldersdrift Health and participation in PHC by the need to examine the process rather Development Programme?” than the impact of community evaluating the collective level participation and put forward a framework (sum of all the results) of and methodology, for assessing Research aim and community participation in the community participation, which would be objectives five sampled PHC projects. applicable to any health care programme. 5. To evaluate the collective level The aim of the research was to measure The factors they considered most (sum of all the results) of the and describe the level of community appropriate, as indicators of community seven sampled community participation in PHC projects of the participation projects in participation, were needs assessment, Muldersdrift Health and Development leadership, organisation, resource Muldersdrift (five projects and Programme. the two management mobilisation, management and focus on Based on the overall aim o f the study the structures). the poor. They did not include the last research objectives were: factor, as it was difficult to convert into 1. To evaluate community an indicator. For each of the other factors participation in the following Definitions a continuum was developed with wide PHC initiatives in the • People-centred approach to participation at the one end and narrow Muldersdrift Health and community participation participation at the other. Rifkin, et al, Development Programme: The people centred approach, or the (1988:937) stated that the indicators’ value • The Joint Management empowerment approach as it is also is two-fold. Firstly, the indicators’ Committee (JMC). called, is “ a process by which the describe differences in community • The Muldersdrift Clinic members of a society increase then- participation over time and by different Committee (MCC). potential and institutional capacities to people. Secondly, they stimulate mobilise and manage resources to • The Elandsdrift Parents/ discussions about community produce sustainable distributed Teachers Association’s participation, which can help the people improvements in their quality of life ‘Thusannang Pre-school involved in the programmes to consistent with their own aspirations” Project’. understand the process better and thus (Korten, 1990:67). A people-centred assist them to achieve better results by • The Muldersdrift Home Trust approach is one of the radical allowing for greater involvement. Foundation’s ‘Our Hope development approaches and argues that (Thembaletu) in Diamond Park participation can only be effective if it is Chetty and Owen (1994:1-12) analysed Housing Project’. community driven (bottom-up), with the 38 Curationis June 2007 community in control to decide about It was contextual in that the results could to evaluate Community Participation in their own affairs and to develop the ability be generalised outside of the specific PHC PHC Projects.” A pilot study was to manage and utilise local resources for projects within the MHDP. undertaken to test both the two research their own benefit (Barker, 2003:13). assistants’ and Muldersdrift • Primary Health Care The MHDP had a study population of communities’ understanding of Chetty The ANC National Health Plan (1994:20) twenty-three (N=23) PHC projects. A and Owen’s (1994) standard evaluation adopts the definition of PHC as defined purposive sample of seven (n=7) PHC instrument. The evaluation tool was in the Alma-Ata Declaration. It reads: initiatives (the two management found to be understandable to all after a “Primary Health Care is essential health structures and five PHC projects) in the few ambiguous words were defined for care based on practical, scientifically MHDP (in 2000) was chosen according clarity. sound and socially acceptable methods to specified criteria. The criteria for and technology made universally inclusion were the following. That: Structured group interviews were accessible to individuals and families in • The PHC initiative had as its aim conducted with the PHC projects’ the community through their full the enhancement of the health executive committee members utilising participation and at a cost that the and/or development of the Chetty and Owen’s (1994) evaluation community and country can afford to Muldersdrift community. instrument as basis. Validity and reliability were ensured according to the maintain at every stage of their • The PHC management structure criteria prescribed by Polit and Hungler development in the spirit of self-reliance had community participants (1997:657). Data collection was simple and self-determination. PHC forms an participating with health integral part, both o f the country’s health as the range of criteria for each professionals to enable component made it easy to choose, by system and overall social and economic community participation in development of the community. Central majority vote, after group discussion, the PHC. This was determined by most applicable criteria. The data was to the PHC approach is full participation the fact that the project: in planning, provision, control and quickly and easily analysed and the □ had a MHDP staff monitoring of services (NHP, 1994:9). results fed back to the respondents member serving as an immediately. The level of community • Partnership enabling member of participation attained was pictorially Stanhope and Lancaster (1988:257) define the project committee, displayed (refer to Figure 1, Figure 2 and partnership “as the informed, flexible, and and/or Figure 4) and explained. The discussions negotiated distribution of power among □ utilised the served to inform the participants about all participants in the process of change Muldersdrift the factors influencing community for improved community health”. In this Programme facilities participation and that the results should research study the partnership concept, for meetings and/or not be seen as a score but as an indicator as defined by Stanhope and Lancaster is □ activities and/or of their increased (broadening) capacities applied throughout. One of the covert □ had a committee and power over decision-making and outcomes of the community participation member serving on the resources in order to improve their health evaluation is to provide the project MCC. and life styles. The component scores partners with motivational affirmation of • The PHC project had a achieved by each project’s participants the level of community participation thus functional project committee were contextually discussed at the end far achieved (Barker, 2003:18). that consisted of office bearers of each interview to provide motivational (Chairperson, Vie-Chairperson, affirmation for the project’s participants. Research design and - Secretary, Treasurer and a The criteria still to be attained, in order to method Project Liaison Officer) and at broaden community participation to the least three ordinary members. next level, was then identified and The research design was evaluative, • The PHC project committee had discussed within the context of each descriptive, quantitative and contextual. at least one member who had The research design was evaluative in project. achieved Grade 12 English. The nature in that the study found out how rationale for this was that at The Joint Management Committee’s well the MHDP’s policy of community least one member had to be able participation (the people-centred (JMC) data was collected via mailed self­ to understand and complete the approach) was implemented utilising administered questionnaires as Chetty tool on behalf of the project Chetty and Owen’s (1994:1-12) evaluation and Owen’s (1994) instrument was committee. instrument entitled “Criteria to evaluate equally applicable as a questionnaire. Community Participation in Primary This method was considered best for the Health Care Projects.” The research In order to demonstrate the extent of the JMC as they would score more honestly design was descriptive as it portrayed community participation in the PHC when alone with anonymity ensured and the characteristics of the community projects chosen, the total membership of it would minimise the time imposition on participation process. It was quantitative each project is presented together with these busy professional officials. A report as it measured the level of community the selected sample and the final sample detailing the results was submitted to the participation by counting the criteria (refer to Table 1). JMC. chosen by the respondents. However Data analysis was not difficult as the three quantitative analytical procedures were The projects were evaluated against component scores obtained were not used to describe the phenomena. Chetty and Owen’s (1994:1-12) averaged to give the score for that factor The results were presented descriptively. quantitative instrument entitled ‘Criteria which was then plotted on the relevant 39 Curationis June 2007 Table 1. Sample selection process and final sample

Community participation PHC Initiative Total membership of the Selected Sample Final Study Sample chosen PHC Initiative

1. JMC 12 12 9

2. MCC 28 28 15

3. Thusannang Pre-school project 120 8 5

4. MHTF 300 8 8

5. The Rietfontein Village association 600-650 8 6 ‘Water Project’

6. The Ladies ‘Sewing and Crochet Project’ 9 9 9

7. The Lesedi Youth Association 18 7 4

Totals (n=7) N = 1087-1137 68 N = 52 radiating arm continuum. Each factor’s participation in the MHDP is expressed consent of the respondents and continuum was connected in a spoke by the sum of the scores for the seven participants were adhered to inclusive of configuration, which brought them (n=7) groups and is visualised by use of principles of respect, dignity, together at the base where participation graphs. confidentiality, voluntary participation was at its most narrow. By connecting and anonymity. Specific informed the factor score on each continuum a consent was obtained from people who spider graph or web graph was produced. Ethical considerations appeared in photographs. Written The study complied with the Code of In order to reflect the variations that often approval (dated 21 November 2002) was Ethics on Human Subjects (Medical) of existed between different components a also obtained from Dr K Chetty and Prof the University of the Witwatersrand and graphical representation of the average P Owen to utilise their evaluation was unconditionally approved scores for each component was used, i.e. instrument entitled “Criteria to evaluate (Clearance Certificate Protocol Number bar graph. The level of community Community Participation in Primary M980507). The criteria of informed Figure 1 Comparative levels of community participation achieved by the PHC projects of the Muldersdrift Health and Development Programme.

Needs Assessment 5 5

♦ Remaining Projects • “ Ladies Lesedi MCC Hi— JMC

40 Curationis June 2007 Table A Factor: Resource mobilisation by the Ladies Project Members Health Care Projects”.

Component To achieve level 5: Discussion of the results The results are presented in accordance Raising funds and/or Committee/community members should take the with the set objectives (1 to 5). The resources leadership role in raising funds. comparative graph (refer to figure 1) shows the levels of community Resources mobilised Level 3 = Moderate amounts raised by committee. participation achieved by the five PHC from the community Level 4 = Large amount of resources raised. Evidence projects. of community voluntarily offering resources. Level 5 = Large amounts raised by means of regular, The Elandsdrift Parents/Teachers planned fund raising initiatives and/or there is a regular Association’s ‘Thusannang Pre-school source o f funds. Project’ (Elands), the Muldersdrift Home Trust Foundation’s Our Hope Factor: Management by the Ladies Project Members (Thembaletu) in Diamond Park Housing Project’ (MHTF), and the Rietfontein Village Association’s ‘Water Project’ Component To achieve level 5: (Rietfontein) all achieved an averaged level 5. This represents the widest level Management by the Level 4 = Committee self-managed, taking of community participation. However as committee responsibility for the greater part of management. can be seen in the breakdown of the Level 5 = Committee/group should become self component scores, a few criteria had still managed. Appropriated utilisation of experts. to be achieved by these project participants to achieve all of the possible Skills development Level 5 = Skills development programmes extent 15 scores/factor (refer to table 1). The beyond the project to community members. Lesedi Youth Association’s Income- generating ‘Basket Weaving Project’ Factor: Needs and Skills Assessment of the Ladies Project Members (Lesedi) achieved level 5 for all factors except resources mobilisation for which level 4 was achieved. The Ladies Income- Component To achieve level 5: generating ‘Sewing and Crochet Project (Ladies) achieved an averaged level 4. Initial needs assessment Community members in general are involved in needs assessm ent Analysis of the component scores (refer to table 2) achieved by the participants Skills identification Active identification and utilisation of all skills identified both the criteria (as delimited by Chetty and Owen’s [ 1994] instrument) Ongoing research and Community/committee utilises own skills to identify to be contextually discussed with the evaluation and carry out research. Researchers are used in an project participants/respondents in order advisory capacity. to provide them with motivational affirmation of their achievements and to indicate to them the mechanisms (criteria) Table B Factor: Resource mobilisation by the Lesedi Youth they would have to implement to achieve Association’s Committee broader participation.

Component To achieve Level 5: The Ladies Income-generating ‘Sewing and Crochet Project’ were provided with Raising funds and/or Level 5 = Committee members take the leadership role the following motivational affirmation of resources in raising funds. The committee had raised seed money their achievements. The Ladies had from Department of Social Services but needed to formed a broadly representative become self-sustaining by raising monies through committee with majority decision making continued productivity of high quality products and amongst the members (level 5). Their funds by developing marketing strategies to increase leader had been elected and was their turnover and sales. supported by the majority, she did not dominate and allowed and encouraged Resources mobilised Level 5 = Large amounts should be raised by means of leadership in the members (level 5). The from the community regular, planned fund raising initiatives and/or a regular criteria as shown in Table A had still to source o f funds. be achieved if the Ladies were to achieve broader community participation. Control over allocation of Level 5 = Committee has total control over allocation resources and utilisation of funds. By becoming self-sustaining The Lesedi Youth Association’s the project would not have to be accountable to the Committee members still needed to Department of Social Services. achieve the criteria in Talbe B. The results of objectives 4 and 5 will be the PHC projects in all components. In committee, who had been so productive presented concurrently. The level of order to demonstrate these differences, in broadening community participation community participation in PHC, in the the scores achieved by these parties are through a wide range of PHC projects MHDP is graphically represented (refer re-presented in Figure 4 (refer to figure involving many different community to figure 2). These results were achieved 4). groups, had lost the power they had by evaluating the seven sampled when enabled by the WITS Department community participation initiatives in the The averaged scores of the five (n=5) of Nursing Education. In addition the MHDP (the five projects and the two PHC projects presented in Figure 4 results of the Joint Management management structures). represents the MHDP’s level of Committee indicate that the Muldersdrift community participation enabled by the community representatives were not The level of community participation people-centred approach to community empowered and they felt they had no achieved by the PHC initiatives, of the participation in PHC projects. The broad power. The Committee was disbanded in MHDP, is an averaged level 4. This levels of community participation the latter part of 2000 apparently due to represents considerable achievements (averaged level of between 4 and 5) disinterest on the part of the members. by the MHDP in broadening community indicate that the people-centred approach This demonstrates the importance that participation w'ithin the PHC initiatives. to community participation was the power over planning and resources The level for each factor presented above successful in empowering the must be in the hands of the community (refer to figure 2) was derived from the Muldersdrift community participants of participants if community participation is average of the composite component the PHC projects. In comparison the to be sustained. scores (average of the component scores Muldersdrift Clinic Committee achieved of all seven of the PHC initiatives slightly lower levels at between levels 3 The people-centred approach to sampled) with the result that part-scores and 4. The Joint Management Committee community participation enabled the occurred (refer to figure 3). achieved between levels 2 and 3. Muldersdrift PHC project community participants (five The levels presented (refer to figure 2) The Muldersdrift PHC project [n=5] sampled) to broaden community require further clarification as the lower participants, who were represented on the participation to between levels 4 to 5 scores achieved by the Muldersdrift Muldersdrift Clinic Committee, were able (averaged 5) [refer to figure 4]. This Clinic Committee and the Joint to broaden their community participation community-based, radical developmental Management Committee diminished the to between levels 3-4 (average 3) and approach, implemented under the scores achieved by the PHC projects through the process they increased their auspices of the Department of Nursing appreciatively. Comparison of the institutional capacities, but they had Education, had enabled the community component scores for each PHC minimal success in forcing a shift in power by authorising the acquisition of power initiative (refer to table 2) identified that over decision making and resources (refer by the community and by ensuring that these structure’s scores were lower than to table 2). This previously very active they had the necessary knowledge,

Table 2. The component scores of the seven PHC initiatives of the Muldersdrift Health Development Programme

Elands. MHTF Ladies Rietfon- Lesedi MCC JMC tein

ORGANISATION Formation of Committee 5 5 5 5 5 5 3.5 Decision making 5 5 5 4 5 2 3 Accountability 5 5 5 5 5 5 3

LEADERSHIP How Chosen 5 5 5 5 5 2 3.3 Allowing Participation 5 5 5 4 5 5 4.6 Role of Other Members 5 4 5 5 5 2 3.3

RESOURCES Raising Resources 4 5 4 5 4 2 2 Resources from the Community 5 5 2 5 4 2 3 Control over resource allocation 5 5 5 5 4 3 1.6

MANAGEMENT By Committee 5 5 3 5 4 3 2.3 By Staff 5 4 5 5 5 3 2 Skills Development 5 5 4 5 5 5 3.3

NEEDS & SKILLS Initial Needs Assessment 4 5 3 5 5 4 1.6 Skills Identification 5 5 3 4 4 2.5 1.6 Ongoing Research and Evaluation 5 5 4 5 5 5 1

42 Curationis June 2007 Figure 2. The level of community participation in PHC projects in the Muldersdrift Health and Development Programme.

understanding and institutional members perceived that the Muldersdrift different approaches to community capacities to identify their needs and to representatives had minimal power over participation. They had not come to a make the correct decisions relating to resource allocation consensus and made their choice of an their health care. The community was (Component level 1 to 2) [Refer to table approach to community participation also partnered in their acquisition of 2], Assessment of community and skills explicit. power and institutional capacities to were confined to the researchers/ mobilise and manage resources or to resource authority. This indicates that The PHC projects component scores force a shift in resources so as to produce the JMC was not committed to (refer to table 2) identified that there were sustainable and justly distributed community participation. Rifkin’s (1981) community leaders who tended to (equitable) improvements in their quality public health approach to community can dominate and did not allow all the of life, consistent with their own be identified in the JMC’s results. The members to participate or only consulted aspirations. This approach has Muldersdrift community leaders were and reported back to the committee on empowered the community participants elected to meet policy requirements; an ad hoc basis. Community leaders who in the MHDP’s PHC projects to a level, however the health professionals due to dominate, who do not consult and who where they will be'able to implement the their expert knowledge retained the power are not accountable to the group, and community participation process on their over decision-making, resources and the who were elected to lead, do not own using health professional/experts as identification of needs and skills contribute to community participation. resources. However the level 4 for assessment. Such leaders are a danger to community resource mobilisation indicates that participation as they depolarise the enablement of a resource authority and The narrow levels (averaged level 2.5) of power from the poor and disadvantaged experts was still required. community participation in the Joint that they are meant to be leading on the Management Committee and the path to empowerment. Such leaders have The Joint Management Committee Muldersdrift Clinic Committee (averaged to be debunked for community achieved minimal broadening in level 3) indicate that the MHDP’s people- participation to be successful. Chetty community participation to levels 2 to 3 centred approach to community and Owen’s (1994) evaluation instrument (averaged 2.5) that indicates that the participation had not been adopted by is an effective debunking tool as it health professionals held the power over the health professionals/resource identifies the criteria required by resources and took all the decisions. The authority responsible for the MHDP. empowering leaders to broaden health professionals/resource holders The three partners i.e. the WRRO, WITS participation. As the community recognised that they dominated the and the Muldersdrift representatives, had participants evaluate their projects, community representatives in decision not discussed the concept community utilising the Chetty and Owen tool, they making and management. The JMC participation and identified that they had learn about the qualities of good leaders

43 Curationis June 2007 Figure 3. The MHDP’s composite component scores.

Formation of committee

Organisation Decision making Accountability

How chosen Leadership Allowing participation Role of other members

Raising resources Resources Resources from community Control over allocation

By committee Management

Needs & Skills

for example not to dominate, to engender component scores and comparative ownership, is achieved. active leadership by all committee factor level graphs. Chetty and Owen’s • Chetty and Owen’s (1994) members, to develop skills beyond the evaluation instrument is recommended instrument evaluates the PHC project of community members and to be for the evaluation of community project’s committee thus the accountable to both the committee and participation in individual PHC projects executive committees of the the project members. and for multiple PHC projects within a sampled projects were PHC programme. The study results evaluated. The results are thus confirmed the findings of Chetty and restricted to the level of Conclusion Owen (1994:3) that the instrument is The study sought to answer the community participation valuable in providing feedback to the PHC question: “What was the level of attained by the executive project participants on their community participation in Primary committee members in the achievements and as a guide to the Health Care projects of the Muldersdrift project. Executive members are mechanisms they would have to take to usually elected because the Health and Development Programme? achieve the next level. The intention of community perceives that they The question was answered, the aims of the tool is to evaluate the participation will do a good job, thus they the study were met by measuring the level of projects, however it is anticipated already possess some skills. In community participation achieved by the that through the evaluation, community future as many PHC projects participants of seven (n=7) PHC projects participation will be enhanced and project members as possible should be of the MHDP by using Chetty and members will be motivated to improve included in the evaluation to Owen’s (1994) evaluation instrument. over time. The set objectives were all achieved. prevent this potential bias. • The results cannot be Chetty and Owen’s (1994) instrument Limitations generalised outside of the entitled ‘Criteria to evaluate Community The limitations identified in the study, specific PHC projects and participation in Primary Health Care were: management structures (MCC Projects’ was chosen as it expanded • The study evaluates the overt and JMC) within the MHDP. Rifkin’s, etal,. (1988:936) assessment tool outcomes of community to suit South African conditions. The participation and presumes that, Recommendations instrument was designed to evaluate by affirming the level of ■ Within the Muldersdrift Health individual projects but this study had participation achieved by the and Development Programme extended its use to multiple projects members of each PHC project It is recommended that CHNs within a programme. In extending its the covert outcomes of responsible for the MHDP function evaluation was significantly development, i.e. enhanced self­ should lobby for the following improved by analysing results of the esteem, dignity, and a sense of changes if the levels of 44 Curationis June 2007 Figure 4. Comparative graph of the levels of community participation achieved by the Joint Management Committee, the Muldersdrift Clinic Committee and the averaged level of the five PHC projects enabled by the Muldersdrift Health and Development Programme.

community participation in PHC and aspirations, and conduct action and secondly, knowledge are to broaden: ongoing research; (ii) conduct of the level of community The JM C’s members, jointly, strategic planning for the participation will guide the should have authorised power broader community; (iii) enable CHN’s practice i.e. guide the over resources allotted to them lobbying from a position of intensity of enabling resources annually by the Gauteng strength (in numbers) and moral offered by the nurse for that Department of Health. The support; (iv) provide the line of project. The evaluation process financial allotment should communication to and from the draws the nurse’s attention to include sufficient funds for both JMC; (v) provide education and the fact that, as the level of health care provision and skills training; and (vi) the community participation development. committee should be allocated broadens the more the CHN’s an annual budget for role changes to that of a health The health professionals, the community participation/ resource person, when health resource authority and development and authorised consulted by the community. the Muldersdrift community legal control over allocation of CHNs are to ensure that they representatives should discuss the resources for which they remain responsible for their approach to community will be held accountable. comprehensive health care, i.e. participation to ensure Recommendations for CHN’s preventive, curative and commitment to the projects. to enable community rehabilitative PHC which For professional health care participation’ practice includes community decisions, the community It is recommended that CHN use development and thus representatives on the JMC the theoretical framework and community participation. The should be provided with the concept ‘enabling CHN is in a managerial position sufficient information to resources’ and implement the responsible for the health of the empower them to make informed following recommendations: community thus both decisions. Evidenced based nursing ‘downstream’/episodic health The Muldersdrift Clinic practice. Evaluation of the level care and ‘upstream’ endeavours Committee should be reformed of community participation are her concern. Delegation of to provide the PHC project attained by project participants community participation in PHC members with a forum to: (i) is essential. Firstly, assessment (community development) to assess community needs, skills is the first step in any nursing Health Promoters, who are both 45 Curationis June 2007 trained and close to the only using CHN researchers in University. community, is recommended but advisory capacity. only if managed by the CHN. • Assessment should be References The CHN offer ‘enabling conducted at the end of a ANC, 1994: ANational Health Plan (NHP) resources’ to the community project to establish summative for South Africa. Johannesburg: African who will only access this evaluation of community National Congress. ‘enablement’ if they know the participation. ‘what, where, when and how’ of Evaluation of their participation BARKER, MJ 2003: Level of Community these resources. The CHN would affirm their participation in Primary Health Care needs to market this developmental gains and projects of the Muldersdrift health and ‘enablement’. The lesson enhance their dignity which in development programme in 2000. M Sc learned at MHDP is that the turn motivates continuing dissertation: University of the regular community events community participation. Witwatersrand. needed to vary for example one • Research is recommended to month something recreational evaluate the subjective BOTES, A 1991: A Functional Approach the next something serious i.e. outcomes of community in Nursing (‘n Funksionele budgeting. The lessons learned participation. denkbenadering ‘n die Verpleegkunde). from organising the recreational ■ Recommendations for nurse Curationis, 14(1), pp. 19-23. activity for example traditional leaders/administrators dance contest could be used at The study identified the CHETTY, K & OWEN, P 1994: Criteria the basis for the next months following recommendations: to evaluate community participation in budgeting lesson i.e. fun, • CHNs in PHC management Primary Health Care Projects. Cape Town: reality based, need orientated positions to have advanced Department of Community Health, learning activities motivated education and training. University of Cape Town. more and more community • Trust/partnership building time participation. GAEDE, B 1994: Social Change and Recommendations for nurse should be considered as on- duty time. Initial contact and Service Development. A Newly researchers in community trust building with a community Urbanising Community. Critical Health, participation takes time spent attending 46,pp.47-52. It is recommended that Community Health Nurses community meetings, social GRAN, G 1983: Development by People: utilise Chetty and Owens (1994) events, funerals and political Citizen Construction of a Just World. New Evaluation Instrument entitled rallies. York: Praeger. “Criteria to evaluate Community ■ Recommendations for nurse Participation in Primary Health educators of CHNs KORTEN, DC 1980: C om m unity Care Projects” to assess the This study has identified that organisation and rural development: a level of community participation CHNs will require training, by learning process approach. Public achieved in every PHC project nurse educators, and additional Administration Review, 40 (5), pp. 498- they participate in / partner. skills to equip them to enable 502. Research recommendations community participation in include the following: PHC. It is recommended that the following requisite KORTEN, DC 1990: Getting to the 2 1st Assessment of community century: voluntary action and the global ‘enabling’ skills are either added participation at the initiation of agenda. West Harford: Kumarian. to or enhanced in the curricula PHC projects to establish a both for basic CHN education baseline against which future MOKWENA, K 1997: Empowerment as and training and in post­ broadening of community a Tool for Community Health graduate CHN/PHCN participation can be measured. Development. CHASA. Journal of education: Evaluation at regular intervals Comprehensive Health, 8 (2), pp. 66-70. • Communication skills should be conducted to provide motivation and to utilise the • Organisational skills POLIT, DF & HUNGLER, BP 1997: instrument’s criteria as a • Leadership development skills Nursing Research principles and method. proactive guide towards J.B. Lippincott Company broader participation. As projects are so different each Acknowledgement RIFKIN, SB 1981: The role of the public This study was completed at the project’s participants should in the planning, management and choose their own concurrent Department of Nursing Education, while evaluation of health activities and evaluation intervals. Broader the second author was a fulltime programmes, including self-care. Social community participation results employee at the University of the Science Medicine, 15, pp. 377-386. in increased potential and Witwatersrand. The article was finally institutional capacities to prepared for publication with the RIFKIN, SB; MULLER, F & mobilize and actively participate assistance of Ms Petro Bester and Ms BICHMANN, W 1988: Primary Health in identifying their own needs, Ronel Pretorius, PhD candidates and Care: on measuring participation. Social skills and aspirations eventually research assistants at North-West Science Medicine, 26 (9), pp. 931-940. 46 Curationis June 2007 RIFKIN, SB & CASSELS, A 1990: Training managers for primary health care: teaching about community involvement. Medical Teacher, 12 (1), pp. 3945.

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