Health policy and programme : The participatory approach

My attention is drawn to "For a more democratic health policy: issues and opportunities" (The Daily Star August 24, 2004). And on a similar note I ask how may anyone be more democratic before first being democratic? As Dr. Zakir Husain (the author of the piece) pointed out that all previous consultation with communities and stakeholders has been aimless and capricious. There was no connection between the beneficiaries and programme evaluation. Even with huge funding and investment, accountability and transparency remained minimal as to "who gets what and when" generally remained vague.

The current dialogue between the government and the development partners focus on funding mechanism for three years (2003-06) on Health Nutrition and Population Sector Programme (HNPSP), previously the Health and Population Sector Programme (HPSP). Nutrition is a central component of Health and Reproductive Health/Population. In 1997 Bangladesh National Food and Nutrition Policy was formulated.

Equally crucial for health reason is the provision of Safe Drinking Water and Sanitation. Was there a need to debate the issue of nutrition vis-à-vis safe drinking water and sanitation for inclusion in the health sector programme?

If there was such a need how and when did this happen?

The long term (2005-10) Strategic Investment Plan (SIP) is concerned with financial heads of programme over the five years period. On going discussion and consultation continues among development partners and between NGOs, professional and research organisations and members of civil society on various programme options. However in this deliberation and dialogue, the deficiency of people's participation in terms of citizen's choice and concern, has been accurately noted by Dr. Rounaq Jahan 'Citizen's voice in health policy and programming' (The Daily Star, August 20, 2004).

There is no doubt that much more need to be heard from the citizenry. It is erroneous to suppose that policy and programme level is insulated and isolated from the general public. Top down and bottom up approach has become the development decorum. Communication, the flow of information needs to be both ways from the sender to the receiver and vice-verse. And in this context it is a myth to suppose that the policy and programme formulation body is always the sender of information and the people at the grassroots the receiver. Field situation shows that the people at large are much more the appropriate source of learning.

In 1995 Government of Bangladesh endorsed a new planning process called the perspective planning process (PPP) covering a period of 15 years (1995-2010) the salient features of the process was its participatory bottom up approach involving the local people in plan (policy and programme) formulation. Much emphasis was given to investment by government and private sector to achieve sustainable economic growth and poverty reduction. It provided an institutional framework at district level for programme implementation.

Also a major policy principle adopted by the National Health Policy was to involve the people in various processes of planning, management, local fund raising, spending, monitoring and review of the procedure of health service delivery. The aim was to decentralise the health management system and to establish people's rights and responsibilities in the system. Thus one of the policy strategies was to integrate the people and the local government with the health service system at all levels.

Government allocation of expenditure budget for health centres from the district to the community would be redistributed within reasonable flexibility. Such arrangement of expenditure fund, it was supposed, would net in the marginalised section of population. Moreover to provide coverage of the health service system to all citizens one community clinic would be established for every 6000 persons.

A committee comprising of health experts, social thinkers and national leaders was formed.. These members then formed five separate sub-committees who prepared several reports to form a draft policy. One workshop was arranged between 15.03.98 and 29.03.

98 in each of the six administrative divisions of Dhaka, Khulna, Barisal, Sylhet, Chittagong and Rajshahi to gather the opinion of the people from all occupations and strata on the draft of the National Health Policy.

Review of the list of participants is indicative of the cross section of local population who voiced their concern and shared their experiences in the policy formulation. Views of individuals and groups belonging to various segments of society was reflected. These included the day labourers, rickshaw-pullers, boatmen, local newsmen, a chronic patient who received frequent medical services, religious leaders, school teachers, male, female, eligible couple, husband, wife, University/college teacher, representatives of the private medical practitioners associations, representative of ayurvedic, unani and homeopathic federation, representatives of local chambers of commerce, NGO representative, principals of medical colleges, BMA representative, pharmacists, village doctors, nurses, midwives, civil surgeons, members of the parliament (party in power/in opposition), health assistants, medical assistant, health inspectors, Thana Health and Family Planning officer, Thana Nirbahi Officer, Paurashava chairmen, Union Parishad chairmen, Thana Family Planning officer, assistant Family Planning officer, family welfare assistant, family welfare visitor, Deputy Director of family planning, Divisional Director of Family Planning, Divisional Director of Health, and Divisional Commissioners.

During field visits comments, views, opinion, remarks, observations, judgement, impression, sentiment, and attitude of the people may be summarized as " ...most often we give our opinion and views and share our concern and hope ... we have not seen nor heard anything done... according to what we said ...or say ... what happens .... what do you all do with all this information ? "

It is then necessary to seriously consider whether the citizen's voice was not heard, or what was said is lost, and there are no records/documentation. It may have been a convoluted communication channel in which the frequency and the wave length were not in unison. Is there a need for follow-up of divisional workshops to re-assess the situation and need to organise people's platform at district or upazila level?

Much more attention is required to be specific, simple and direct on health related subject matter for people's participation. Sufficient evidences from field situation are available to support that level of literacy is not always co-related with pragmatic proposals and plan of action. And those who are responsible for the plan and programme formulation may lack in capacity to accommodate the voiced opinion and views of the people at large.

Experts, specialists, activists and field workers connected with the health sector programme are already familiar with the opinion and views of the people at large. However, if within the upcoming HPNSP and SIP were to propose activities which are a departure from the past, then it is mandatory to seek fresh opinion at the grassroots level preceded by communication to clarify the changes/modification. Communication material to support these remodeling need to be prepared and health educators positioned for dissemination of the health related information.

Just as people's participation is important during policy and programme formulation, it is equally important in the implementation phase, particularly in connection with monitoring of project activities, and evaluation after completion of activities.

The national monitoring agency IMED (is engaged in detail study on some 1200 projects annually) prepares review reports on seven major areas when a large project implementation is completed. One of the areas is benefit analysis, (cost benefit analysis) though this is not reflective of beneficiaries' participation in the project, specially in terms of health benefit. For a few selected projects IMED conducts ex-post evaluation. The Population Division Evaluation Unit/Planning Commission was transferred to IMED now undertakes this activity.

The responsibility for impact evaluation of projects rests with the administrative agency and the IMED, though it is supposed that there is a lacunae of skill and experience in this field. The development partners introduce their own monitoring and evaluation system. Both (national and DP) these system operate independently though linkages do exist. However it is a matter of grave concern that "Government and development partners ...appear to lose interest during implementation." (R.Jahan/DS/August 20, 2004). This means that monitoring and evaluation is relegated to secondary position. The success of the project in terms of number of people who directly benefited usually is vague, as the beneficiaries are generally not asked, (Z.Husain/DS/Aug 28, 2004) and sometimes if they are asked it is in a casual manner, or with a close ended questions to some women participants who may vaguely know something or not know anything about the project.

Monitoring is carried out mainly through progress report which is prepared by the project management. (Generally the Project Director is too busy to do this work. It is prepared by the consultant. The beneficiaries' involvement depends on the consultant's field visit and interaction with the people at project site).

The planning wings of several ministries including Health Population and Family Welfare are understaffed and ill-equipped to carry out the planning, monitoring and evaluation functions effectively. Further the effectiveness of operational research for monitoring and evaluation of health programmes suffer due to inadequate budget allocation for research purposes in the various research institutions of the country.

Under the prevailing situation participatory monitoring would bridge the widening gap in monitoring and evaluation of health related projects, initially on selective basis, and depending on the effectiveness and cost of the method it could be extended to more areas.

Participatory Monitoring is a much practiced management tool among the NGOs. Already civil society organisations have initiated monitoring through community based committees. Such milieu allows for continuous empowerment of the people. It is learning by doing. A sense or ownership begins to develop. More and more the members of the community take responsibility of what happens and the tendency to blame others begins to disappear.

Participatory monitoring is continuous observation, reflection and correction of action by the people themselves. It is easy and cost effective when people themselves observe what concerns them. When they note things that work out well, it motivates the people to continue, and when poor result are observed people reflect and take steps to redress. All this may initially appear to be a time consuming process.

Thus there is an urgent need to put our heads and hearts together in evolving a balanced strategy for health policy and programme that accommodates people's participation in terms of their expressed concern and interest and their appraisal of the end results. The dimension and the space of this framework must look to the future possibilities and requirements within the health sector, reflective of past performances and the lessons learnt.

Farida Shaikh, a sociologist is former consultant, WHO-DPHE Programme.