Summary

Community participation is one of the major aspects in the re-orientation of Primary Health care (PHC) in Cameroon. In course of our situational analysis of May 2001, we realised that community participation was not oriented towards community empowerment. Our intention is to achieve community participation as an objective per se but the factors that hinder the process of community empowerment are not known. We therefore opted to conduct a facts finding survey (KAP) with respect to community participation in THD to identify the true hindering factors in order to take appropriate actions.

Background

It has remained for long unconceivable to look at community participation as an end per se. i.e. as a social process towards the development of self-reliance. This translates the endogenous capacity of the community to influence the decisions taken on its behalf. Our pre-occupation is that community participation as is currently practised in Tiko does not favour community empowerment and our action aims at a true transfer of decision making to the people in the community.

We are aware that developing community participation within the context of self-reliance is a complex process, which cannot benefit from a simple recipe. Faced with a number of unanswered questions we planned to undertake during the period 2001-2002, a fact-finding survey (KAP) marking the beginning of an action-research approach in developing community participation in the Tiko Health District.

The research problem was that the factors (knowledge, attitudes and practices) hindering the effective transfer of decision making to the people in the Tiko Health District are not known.

The practical aim we set out in this study is therefore to identify the factors (knowledge, attitudes and practices) that influence community involvement, commitment and participation within the conventional dialogue structure setting as well as to explore other avenues for community participation in order to adapt appropriate strategies towards transferring decision making to the people.

Presentation of Tiko Health District

The THD is situated in Tiko sub-division within the Fako division SWP. Fako division is one of the 6 administrative divisions of the SWP and it has 4 health districts including Tiko. The THD has a surface area of 484 square km with a population density of 228 inhabitants per square kilometre. The climate is hot and humid through out the year with the dry (from November to March) and rainy (April to October) seasons alternating. The THD is accessible all the year round by land (80%) and by water (20%). The furthest distance would be 4 to 6 hours by boat and 3 to 4 hours by land. There are no major physical barriers except for water (see map fig 1).

The Tiko health District (THD) is one of the 14 health Districts in the South West Province and is sub divided into 8 health areas with each having a leading health centre. Three of the leading health centres are parastatas (CDC) while five are public. The THD follows the administrative boundaries of the Tiko sub-division, though for easy accessibility, Tiko is supervising the Kange health area, which normally is under the Limbe health district. The boundary of the THD with the littoral province (Mungo and Wouri divisions) is not clearly defined and as such there is always confusion with regards to which district covers the Besco fishing ports.

The socio-cultural, religious and economic characteristics of the Tiko health District is that it is a cosmopolitan district with a lot of inter-frontier and ethno-cultural mix between Cameroon and Nigeria. The resident nationalities are thought to be mostly Nigerians (54%), Cameroonians (45%), and others (1%). The following tribes can be identified: Bakwerians, Balis, Bafwums, Bafut, Douala, Balundus, Bamilikés, Ibos, Yurubas, Fulbes, Banso, Oku, Bakossi, Bayangi, Ijagams, Balong, Moghamos, etc. Religious practices are mixed: Christians, Muslems, Bahai.  Subsistence activities of the population include: Farming, Fishing, poultry and animal husbandry.

The economic (both at micro and macro scales) activities include: Industrial farming (CDC, Delmonte), Medium size industries (metropolitan plastics, Brasseries, Sand exploitation, fishing, Transfrontier trading, Sea and Land Transport).

In the Tiko health District there is a sub-divisional administrator (DO), appointed by the head of state administers at the Tiko sub-division who is responsible to the ministry of territorial administration. The activities of all the other government sectors are under his administrative coordination and control.

A system of local government authority (municipal council) equally exists and a mayor is democratically elected from his peers of councillors. Councillors are the direct representatives of the people. However, the council authority is not independent of multi party political influences. The central government equally oversees the governing of councils through appointment of a secretary general to the municipal council.

Research Questions

The general research question was what factors are influencing community involvement, commitment and participation within the conventional dialogue structure setting and what other avenues can be explored to enhance self-reliance?

The specific research questions are:

1. What knowledge do partners in PHC (health professionals and community) have with respect to community participation?

2. How do they behave towards community participation?

3. To what extent are their knowledge attitudes and practices bringing them closer to self-reliant development?

4. What do they suggest can be done to improve community participation?

Method

The study design is that of a KAP survey that involved all the leading actors (health staffs holding posts of responsibility and community representatives in the dialogue structures)

1. Semi-structured questionnaires were the instruments used to collect data on the knowledge, attitudes and practices as well as suggestions towards improving community participation. Two different sets of questionnaires were administered accordingly depending on whether data was collected from the community or from a member of health team. Health staffs holding posts of responsibility, the majority of community representatives in the dialogue structures and some inhabitants in the community participated in this study.
    

2. The Rifkin scale was used to assess the level of community participation. The District Medical Officer (DMO) moderated two group discussions. The members of the District Management Team (DMT) attended the first session, while community representatives in dialogue structures and the Chiefs of posts of health Areas attended the second session. Decisions were arrived at by consensus. The results from the two groups were compared.
    

3. Two community representatives administered the questionnaires: one of them was a secretary in the Holfort Health centre fund management committee, and the other the secretary of the district health committee. They did not act as respondents. The chairman of the district management committee and the district medical officer (DMO) supervised them.
    

4. EPI Info 6 software was used to analyse quantitative date while content analysis was used for qualitative data.

Results

Profile of respondents

In all, 48 respondents (table 1) from 32 different communities (urban and rural, public and private) participated in this study and 96% of them had responsibilities in decision making for community benefit either in the capacity of health staffs, health committee members or local opinion leaders.

1. Ten health personnel responded to the questionnaires and all of them were holding posts of responsibility (7 chiefs of posts of health centres, the District medical officer, the chief medical officer and the Chief of Bureau for health). Most of them have been holding the same post for at least 8 months (average 31 months)
    

2. 38 persons from the community also responded to the questionnaire.
    

Knowledge of Actors with respect to community participation

To assess their knowledge, different sets of questions were asked to respondents depending whether they were health staff or community representatives.

The judgement on the type of knowledge was based on the qualitative assessment of the answers given by respondents on the topic being assessed compared to what we have considered as standard answers. The percentages on table two are the measure of how close they were to the standard answers.

It is particularly interesting to note that irrespective of the actor (health staff or community representative), the claim of knowing (answering yes to a question like ‘do you know….’? and corroborating this claim in the follow-up question like ‘what therefore is …’? is widely divergent. What is thought to be correct is not correct in these cases.

Attitudes and Practices in the process of involvement and participation

All respondents believed that community participation in primary health care was important and gave various reasons why this was so. In practice, dialogue structures have been set up in five health areas run by the public sector. The three health areas run by the private sector i.e. the Cameroon Development cooperation (CDC) has no health Area dialogue structures. However, the various residential camps for the CDC labourers have what has been called the ‘camp health committees’, which handle aspects of hygiene and sanitation in their environment and have no other role in the management process of health care.

At the district level, no district management committee (DMC) exists. The hospital management committee (HMC) is not an operational arm of the health district committee (HDC).

When one takes a closer look at the process of putting in place these dialogue structures where they exist, one realises with dismay that the notion of representativeness has been ignored, such that interest groups such as like Youths, Women, NGOs and Village councils are not adequately represented. The members of these dialogue structures clearly manifest a low level of motivation and of commitment within the context of self-reliant development as their response to meetings, supervision and control of community pharmacies remain insufficient.

Level of community empowerment and the hindering factors

The results based on Rifkin scale show clearly that community participation in Tiko Health District in the year 2001-2002 was well below performance level 3 as illustrated in figure 1 below. There was no difference with the results obtained in both groups during the two sessions.

Suggestions made by respondents to improve community participation

9 different categories of suggestions were collected. The first 6 categories are common across the actors.

Discussion

Knowledge, attitudes and practice

One can define community participation as a social process towards the development of self-reliance. This translates the endogenous capacity of the community to influence the decisions taken on its behalf, a true transfer of decision making to the people in the community.

The KAP survey has revealed that the main actors do not clearly know the meaning and goal of community participation. Their current knowledge on community participation is in itself a limiting factor towards attaining community participation.

The fact that all respondents thought community participation was important translates a positive attitude. Unfortunately without a good understanding of community participation, this positive attitude does not translate a positive outcome in practice. Further more; the lack of required skills by actors to manage the health system aggravates the situation even more. Even the suggestions made by respondents on how to improve community participation are limited in scope as a consequence of their narrow understanding of the subject. Any improvement in knowledge will influence community participation positively.

What Options For Developing Community Participation In THD?

PHC recommendations for developing partnership and participation of the community is through co-financing and co-management.

The PHC recommendation is to involve the community through dialogue structures (representative democracy) wherein community representatives are incorporated into health management structures (made up of both the health sector and community partners) to constitute an interface of dialogue between the community and health staffs (fig 2). Conceptually this approach implies that the identification of health needs, the planning, implementation and evaluation of health related programmes become an attribute of these structures within contextual settings. Many such committees have been created in the process of developing community participation except in the CDC run Health areas where only camp health committees exist. These camp health committees are equivalent to inter village health committees. The latter have not been organised into health area dialogue structures.

Ngum (2000) reports that the creation of dialogue structures are not withstanding, the main means for dialogue remains direct communication between providers and users using other channels (interface) of dialogue. According to this paper, proper use of a suggestion box can decentralise participation directly to individuals as beneficiaries of services offered to the public. This approach obviously opens perspectives towards direct participation in problem solving in Health units towards empowering patients as an interest group using the given health unit.

We have identified two levels of the local councils; the village or quarter council on one hand and the municipal councils on the other hand.

The most decentralised of all is the village/quarter council. It is a democratised structure led by the village or quarter head or local chief. It is governed following socio-cultural values of each given village or quarter. However, the degree of democracy will vary from culture to culture and from one social structure to another. This council serves as the development structure of the village and the majority in the community accept its decisions. In most cases, these village councils have members who are responsible for health related programmes. Unfortunately as our study has revealed, the selection of community representatives tend to ignore the already existing community structures that pursue same objectives.

Even though the local Tiko Rural Councils in principle are the most recognised and regulated democratic community organisations at the level of health districts no suggestion was however, made by the respondents with respect to the role the local councils could play in enhancing self-reliance.

Conclusions

Lessons learnt

The results of this KAP survey have enabled us to understand that the knowledge the main actors have on community participation is inadequate, though their attitude remains positive towards community participation. What they practice in this domain is limited by the present level of knowledge and the lack of required skills to manage the system. However, this practice can improve tremendously with the acquisition of the right knowledge and skills.

The study also permits us to understand that the acquisition of the right knowledge and skills alone is not enough because a good level of motivation is necessary to keep the health staff willing to involve the community and for the later to participate.

Finally, we have learnt that while other avenues and opportunities for community participation remain unexplored and even then unthought-of by the main actors, technical material and financial support to facilitate implementation of community plans is a pre-requisite for the process of community participation to effectively take root in the THD.

Actions to Take

Given the findings of this study and the discussions advanced, the following practical conclusions are drawn:

1. Carry out continuous sensitisation, education and communication in favour of community empowerment on individual and collective basis.
    

2. Renew dialogue structures based on the principle of representative participation with the integration of local village council structures, youth and women groups as well as NGOs.
    

3. Help organise CDC camp health committees into health area dialogue structures.
    

4. Train both health staff and community representatives in the Tiko health district to enable each of them play their role in community participation accordingly.
    

5. Supervise and provide technical, material and financial assistance to dialogue structures in their process of planning, implementing, monitoring and evaluating health programmes.
    

6. Put in place the following ways of motivating the members of dialogue structures:
   - Mobilising resources to finance budgeted plans of actions,
   - Awards and rewards of best performances, congratulatory letters), as well as
   - Create incentives to encourage health staff work towards community empowerment such as performance contracts, civil society pressure, and community participation as one of the criteria for best health area awards.
    

7. Encourage more direct channels of participation like suggestion boxes, focused group discussions, etc to complement representative participation.
    

8. Conduct research to assess the role and feasibility of having the municipal councils steer community empowerment in favour of health issues.
    

9. Identify more opportunities and promote community initiatives in favour of self-reliance.

Acknowledgements

Our acknowledgements go to Dr SALPOU Daniel of the Lutheran Church Evangelical Health Services, Ngaoundere and to Dr. Mrs NGUM nee Halmata BELYSE of the Provincial technical group for the malaria control programme (PTGCM), SWP.

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