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Health intervention as a catalyst for community development : A case study of the Nong Khaem mother… Jawanda, Kimindra 1994

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H E A L T H INTERVENTION AS A C A T A L Y S T FOR COMMUNITY D E V E L O P M E N T : A C A S E STUDY O F T H E NONG K H A E M M O T H E R & CHILD H E A L T H PROJECT (Bangkok, Thailand) by KIMINDRA JA WANDA B.A., UNIVERSITY OF BRITISH COLUMBIA, 1986 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF T H E REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES School of Community and Regional Planning We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA November 1994 © Kimindra Jawanda, 1994 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. 6LMI Department of The University of British Columbia Vancouver, Canada DE-6 (2/88) ABSTRACT By the year 2000, urban areas will be home to more than fifty percent of the world's population. The rapid rate of urbanization particularly in the developing world will no doubt lead to an increase in slum and squatter communities. In conjunction with this growth, there will be a lack of both physical and social infrastructure, and urban problems will become even more acute than they are today. There is a growing realization that growth management policies have to be put into effect in order to deal with the creation of these mega-urban regions: policies which recognize the absolute need of participation of all the players involved. This thesis examines two themes: (1) the role of a local non-governmental organization (NGO) in an urban poor site in Bangkok, Thailand in promoting community development and; (2) the establishment of a primary healthcare unit and its use as a catalyst for further community development, in which women are targeted as the agents of change. Questionnaires and informal discussions were conducted with the community residents and leaders; NGO staff; local municipal authorities and with other NGOs. The principal findings were the following: (1) the poor can articulate their needs and are able to assist themselves if given the training and resources to do so; (2) there should be better coordination between the players involved, ie - the public, private and voluntary (including community residents) sectors of society; (3) health as an initial entry feature into a community can prove to be a successful mode in advancing community development; (4) by training the women in the community as both health care workers and daycare workers, the facilities will have a better ii chance of being sustained once the NGO pulls out; (5) the community should play a crucial participatory role in the designing, implementing and monitoring stages of any development project and; (6) by decentralizing activities to the local level, aid becomes more effective. iii T A B L E O F CONTENTS ABSTRACT ii T A B L E OF CONTENTS iv LIST OF TABLES vi LIST OF FIGURES vii LIST OF MAPS viii ACKNOWLEDGEMENTS ix DEDICATION x C H A P T E R 1: INTRODUCTION 1 1.1 Introduction and Motivation of Study 1 1.2 Research Problem and Questions 3 1.3 Methodology and Organization 3 C H A P T E R 2: R O L E O F VARIOUS ORGANIZATIONS IN COMMUNITY D E V E L O P M E N T 7 2.1 Introduction 7 2.1.1 Definitions of Concepts 9 2.2 Strategies Used by Different Interest Groups in Achieving Community Development 10 2.2.1 Role of Government in Community Development 10 2.2.2 Role of NGOs in Community Development 12 2.2.2i NGOs in Thailand 16 2.2.3 Role of Community 18 2.2.4 Role of Women in Gender and Development (particularly in health service provision) 21 2.2.4i Women in Thailand 25 2.3 Catalysts for Community Development & Poverty Alleviation Programs 28 2.3.1 Urban Community Development Project 28 2.3.2 Entry into Community 29 2.3.3 Consolidation of Efforts 30 2.3.4 Community Organizations 31 2.3.5 Transfer of Responsibilities to Community 34 2.3.6 Self-reliant development 34 2.4 Summary 37 iv C H A P T E R 3: H E A L T H INTERVENTION AS A C A T A L Y S T FOR COMMUNITY D E V E L O P M E N T 38 3.1 Introduction 38 3.2 Case Study - Nong Khaem Mother and Child Health Project 40 3.2.1 Project Background 40 3.2.2 Community Profile 45 3.3 Project Involvement 55 3.3.1 Role of Funding Agency - Canada Fund 55 3.3.2 Role of Non-governmental Agency - Foundation for Slum Childcare 57 3.3.3 Role of Local Government - Bangkok Metropolitan Authority 59 3.3.4 Role of Community 62 3.4 Summary 66 C H A P T E R 4: T H E RESULTS O F PROJECT INTERVENTION: COMMUNITY VIABDLITY A F T E R NGO/CIDA ASSISTANCE? 68 4.1 Introduction 68 4.2 Changes Implemented in Nong Khaem Community 68 4.2.1 The Community: Pre NGO 68 4.2.2 NGO Involvement: Community Development Initiatives 70 4.2.2a Health Clinic 74 4.2.2b Daycare Centre 75 4.2.2c Playground 79 4.2.2d Social Development Activities 79 4.3 Post NGO: Community Viability? (sustainability) 82 4.4 Summary 84 C H A P T E R 5: CONCLUDING REMARKS AND RECOMMENDATIONS 86 5.1 Introduction 86 5.2 Project Beneficiaries 86 5.3 Recommendations: Sustainable Development Initiatives for Nong Khaem . . . . . 88 5.4 Summary 95 BIBLIOGRAPHY 96 APPENDIX A Nong Khaem Questionnaire: Community Residents 103 APPENDIX B Questionnaire - Response Key 108 v LIST OF TABLES Table 2.1 Stages of Community Development Approach 21 Table 2.2 Three Generations of NGO Development Program Strategies 35 Table 3.1 Waste Dumped at Disposal Sites 51 Table 4.1 Interviews Conducted at Nong Khaem (June-August 1993) 68 Table 4.2 Programs and Activities Initiated by NGO 80 vi LIST O F FIGURES Figure 3.1 Respondent's Land Title 42 Figure 3.2 Length of Stay in Nong Khaem 47 Figure 3.3 Length of Stay in Bangkok 48 Figure 3.4 Birthplace of Respondents 49 Figure 3.5 Monthly Household Head Income 52 Figure 3.6 Place of Work 53 Figure 3.7 BMA Organization Chart 60 Figure 4.1 Use of Health Care Facility by Gender 76 Figure 4.2 Use of Day Care by Monthly Household Income 78 vii LIST OF MAPS Map 3.1 Districts of Bangkok 41 Map 3.2 Location of Garbage Dump Sites in the Bangkok Metropolitan Area . . . . 42 Map 3.3 Nong Khaem Site Plan 43 viii ACKNOWLEDGEMENTS This thesis could not have been completed without the assistance and guidance of Dr Anne-Marie van den Bosch, the project manager of the Mother and Child Health Care project. Anne was able to introduce me into the community and I was able to learn so much more through her own experiences that I would have not been able to do on my own. I would like to thank Jake Buhler, Isabel Kelly and my adopted Thai family for offering support in Bangkok while undertaking my research. I would also like to thank my advisors Aprodicio Laquian, Michael Leaf, Terry McGee and David Clayton for their helpful advice over the past two years. ix DEDICATION / would like to dedicate this thesis to my parents. x CHAPTER 1 INTRODUCTION 1.1 Introduction and Motivation for Study As international development aid has existed for several decades, the question that appears to the author's mind is "how effective has it really been in terms of meeting the needs of the target population?". International donors have made decisions on behalf of the target group, which have had far reaching negative implications. This has resulted in call for alternative methods in providing effective funding so that ultimately "development" can occur in a positive manner. This thesis will provide one example, by way of a case study, to show the reader that there are possible solutions to help alleviate the situation of the urban poor. International development aid, if provided with no strings attached, can be effective for the poor. This case study is one example of how administering funds in a positive manner has been undertaken through a local non-governmental organization. The NGO has been able to establish contact and the respect of the community it is working on behalf of. The decision in terms of the type of projects that will be undertaken should also be established with the community at large. Thus, a participatory model should be used in which all the stakeholders that are involved have some input in the outcome of the project. 1 For any development aid project to be successful, one needs to recognize that the outcome of project initiatives must be sustainable or viable over the long term. If the project is not viable in the long term, then the funding may be better utilized in another way. Development should be a catalyst for further action to take place. Ultimately the community will have to take ownership for the sustainability of its community in order for it to flourish and survive. This is one of the basic questions that will be asked in this thesis: "Will the community be able to sustain the activities that are being implemented with the help of the NGO once the NGO leaves the project?" This thesis will focus on the role of a NGO in promoting community development in a community which lacked the social infrastructure to do so on its own; the role that the community has played in achieving community development (with particular emphasis on the role of the women); and how the community may sustain itself over the long term. The general purpose of this study is to provide some evidence to support the essential role of women and the role of non-governmental organizations in third world community development projects. The author believes that the role of these groups must be incorporated into any developmental proposal from the onset and a participatory role must be undertaken by all the players involved. The primary motive for this study is to understand how international aid can be an effective mechanism for assisting the urban poor. As aid will most likely continue to be 2 provided to many of the developing countries, the author believes that understanding the realities of aid, and both the successes and failures of projects, will benefit people to work more effectively in development work. 1.2 Research Problem and Questions The research problem that the author attempts to address in this thesis is how international development aid can be effective in reaching the urban poor population (bottom 20% of society in the developing world). As basic needs are not being met for many of the urban poor residents, it is crucial that alternative methods for achieving community development be found. With our present day world population being estimated at 5.67 billion and heading for six billion in 1998 (Greenaway, 1994), it is critical that the issue of meeting the basic needs of this population be considered. In the course of the research, three questions were explored: (1) how can international development aid actually reach the bottom 20% of society; (2) can an NGO play a catalytic role in a community to further development and (3) what can an NGO do to encourage community viability once it becomes involved in a project? 1.3 Methodology and Organization The approach selected to explore the role of an NGO and the role of women in a community development project was through a case study undertaken in Bangkok, Thailand (May-August 1993). 3 To develop this case study several research methods were utilized: (1) Interviews were conducted formally and informally. Informally, the researcher interviewed local government officials; other NGO officials (international and domestic) working in Bangkok; and NGO staff and community workers who worked on the project. In addition to these informal interviews, formal structured interviews (by means of a questionnaire, see Appendix A) were administered to the community residents; health care and daycare workers; NGO staff and community leaders (both informal and formal). The types of questions formally asked were both open-ended and closed in nature. Findings from the questionnaires will be discussed in detail in chapter four. (2) Participant Observation. This technique was used by the researcher when visiting the urban poor community. By being on the site, information was gathered through both observation and informal discussions with the NGO staff and community workers. The researcher was able to observe the interaction between the NGO staff, community residents at the daycare and health care facilities as well as in the community. (3) Collection of secondary data from a number of sources (journals, articles, books, newspapers and previous studies). (4) Unobtrusive observation during regular site visits. The researcher tried remaining unobvious during visits to the project. The questionnaires were translated into Thai and were verbally applied to community residents by the NGO staff. The sample size was selected from the parents who picked up their children from the daycare center; from the community residents selected randomly; and from the health care and daycare workers who worked in the facilities. Upon completion of the questionnaire, the researcher had the questionnaire translated into English. In order to ensure that the questionnaires were being administered effectively, the researcher accompanied the NGO staff member into the community during the site visits. Leading questions were not used in the analysis of the findings. The researcher's knowledge of the Thai language enabled her to ensure that the questions were being asked as intended. However, due to cultural differences some questions had to be discarded during the analysis stage. 4 The researcher encountered some limitations during the course of her thesis field work. One limitation was that the researcher was always accompanied by NGO staff when visiting the community, and was forbidden to visit the actual garbage mountain. Thus, she was unable to observe the spontaneous nature of the community residents. On the other hand, given the time limit (which was another limitation), the researcher was at least accepted by the community, because of her association with the NGO. Given the time constraints, it helped that the researcher had previously lived in Bangkok. The questionnaires were analyzed using a standard statistical program (SPSS). Many of the findings by the researcher matched that of the survey conducted by the NGO in 1990, prior to implementing the project. For further information on the findings, please refer to Appendix B. Chapter two is a literature review dealing with issues on the role of different organizations working in international development. The hypothesis is that the further one gets from the international aid donor to the community level ('grassroots'), the more effective and appropriate aid will be. The chapter also examines different catalysts that can be used for initiating community development activities. Chapter three is the descriptive chapter in that it provides background information on the project and on the community that was selected for research. Following this, there will be an examination of the players involved in the implementation stages of the project. 5 In chapter four, the primary findings of the researcher's work are discussed. It should be noted that the author will refer to the questionnaire conducted by the NGO as the "survey" and use "questionnaire" to refer to the author's work. Reference is made to whether or not the community played a role in the decision-making, implementation and monitoring phases of the project. The project is perceived as being successful (to the NGO and the funding agency and for the community) in achieving its outcome and encouraging community development; the chapter attempts to discuss the viability of the community to sustain itself over the long term. The final and concluding chapter offers some recommendations based on the researcher's field work and theoretical knowledge of community development issues. 6 CHAPTER 2 R O L E O F VARIOUS ORGANIZATIONS IN COMMUNITY D E V E L O P M E N T 2.1 INTRODUCTION The economic indicators (ie. GNP) of the quality of life have been quite impressive in many Asian countries over the past two decades. However, it is necessary to keep in mind that these impressive figures most often do not reflect the conditions of the poor in the countries (especially the bottom 20 to 40% of the population). According to Getubig (1991: xi), it is "probably safe to assume that these improvements in the quality of life have not percolated down to the poorest in view of the highly unequal income distribution". Thus poverty exists not only because developing countries are generally poor, but also because of the highly inequitable character of the social, economic and political relationships. Traditional development theory emphasizes that development is primarily a function of capital investment and that the greater the flow of capital from wealthy countries to poor countries, the more rapid the development of the latter (Getubig 1991). In the past the practice for conventional practice has been to concentrate developmental resources in the hands of central government and bureaucratic structures in order to achieve optimal resource allocation. According to Korten (1987), this has resulted in the use of development resources to maintain vast national patronage systems and has ultimately placed an increasing dependence on external resources, and further aggravated the concentration of wealth and political power. 7 In addition to the inadequacies of traditional development theory, relatively less attention has been given to the urban poor: who have been largely neglected by many governments. The emphasis has been on development work which has mainly focused on alleviating poverty in the rural areas of third world countries. Governments in the third world have faced the urban poor with "dismay, watching their mushrooming settlements engulf the physical structures of the modem state and the besieged vestiges of gracious living" (United Nations 1990: 4). The urban poor have been perceived as both a housing and infrastructure problem rather than as a social resource and the fastest growing component of civil society. With this frame of mind, the role of the state has been confined to supplying selected services in accordance with budget constraints. Attention and resources have mainly been in the form of infrastructure provision in the urban areas which has benefitted the urban elites, and not the urban poor. Macro-economic policies in the developing countries have implicitly assumed that the benefits would filter down to the poorer sections of society (Getubig 1991). With an increasing amount of people in the urban centres, policies have to be in accordance to address the 'real' needs. In targeting the urban poor, it is only in the recent past, that there has been a shift in a perceived anti-urban bias. Several UN agencies and international non-governmental organizations (NGOs) have been increasing their resource allocations to the urban areas of developing countries, with particular attention being paid to the urban poor. Nevertheless, the resources allocated to this huge and needy population remains small compared to the actual needs. 8 With the introduction of the above background information, the focus of this chapter will be an exploration of strategies that can be used by international organizations, government organizations (GOs), non-governmental organizations (NGOs), and by the local communities in dealing with the issue of urban poverty. The case study that will be presented is an urban poor community located in Metropolitan Bangkok: Nong Khaem Garbage Slum Community, which is the research area for this thesis. 2.1.1 Definitions of Concepts Before continuing with this chapter, it is necessary to define some of the terms that will be used often throughout the paper: 1. Community participation is the process by which the people participate in the development efforts. This effort includes the readiness of both the government, NGOs, and the community to accept certain responsibilities and activities. It also means that the value of each group's contribution is seen, appreciated and used (Yeung and McGee 1986: 97). 2. Poverty means human deprivation of the basic needs of life such as food, health, education, shelter, clean drinking water, and basic social infrastructures (Getubig 1991: 5). 3. Non-governmental Organizations will be defined, in this thesis, as local non-profit, private voluntary agencies which concentrate more on development-oriented activities than charity or social welfare work (Kiatiprajuk 1992). 4. Urban community development is basically an on-site program. It attempts to improve the economic, social, and political conditions existing in small urban communities, through the organized efforts of the people themselves as assisted by trained community development workers. Ultimately, it attempts to bring about change in the people's attitudes, values, conditions and opinions (Laquian 1969: 45). 9 5. Community Organizations are the autonomous bodies formed by the local communities themselves for their own development (United Nations Volunteer 1990: 2). 6. Community in this thesis, is defined as a group of individuals occupying a specified geographical area sharing common values, and interacting with one another to achieve common goals. Includes socio-economic structures designed to achieve the continuance of the community and its development and improvement. According to Redfield (1960), a community has the qualities of distinctiveness, smallness, and homogeneity. 2.2 STRATEGIES USED BY DD7FERENT INTEREST GROUPS IN ACHIEVING COMMUNITY DEVELOPMENT 2.2.1 Role of Governmental Organizations (GOs) For many government agencies, poverty alleviation is merely a by-product of development (Getubig 1991: 43). Development is expected to occur as certain resources are funnelled through the traditional delivery systems. According to Laquian (1969), government's participation in urban community development programs has usually involved: 1. recruitment, selection, training and remuneration of the urban community development workers. 2. provision of program resources such as grant-in-aid programs involving roads, schoolhouses, health centres, etc. 3. provision of operational resources such as medical facilities, supplies and materials, vocational kits, etc. Korten (1986) argues that development projects have been designed in national and regional centres, with government personnel hired to serve the 'beneficiaries'. This has often led to the failure of projects, as many of these officials have no 'real' understanding of the needs of the target population and nor do they have a keen interest in working with the poor. 10 The major instrument of government urban policy used is that of devising urban plans (master/comprehensive plans), which rarely show reference to the actual socio-economic conditions of the majority population. For the government, the basic issue in dealing with poverty is employment and income generation. Little recognition is given to issues of location of employment, availability of shelter, work and retail space, patterns of transportation to and from work, etc. Governments have often been reluctant to provide the necessary leadership to a community and have also lacked the capacity to address many of the issues involved. To some extent the local/municipal governments are somewhat closer to addressing some of the problems, but they have also been the objects of severe budgetary expenditure cuts. Though the responsibility and burden of dealing with urban poor issues in developing countries keeps on increasing, the available resource base continues to decline and it becomes more difficult for governments to deal effectively with the urban plight. The establishment of non-governmental organizations has to a large extent been in response to the limited impact that governments have been able to make. NGOs are more likely to have a natural interest in democratization and face fewer organizational constraints in undertaking actions (Korten 1987: 2). However, though NGOs are able to mediate to some extent between the state and the community level, there still needs to be a recognition at the state level that specialized programs targeted specifically at the urban poor may have to complement macro-economic policies that promote equitable growth. As an alternative to central planning, 11 Korten argues for the need for 'micro-policy' reforms, which are reforms that "depend on their implementation on the accomplishment of sometimes highly complex and difficult institutional changes commonly involving the development of significant new institutional capacities and norms and a redefinition of institutional roles" (Korten 1986: 310). Korten (1983) suggests that there are four key limitations of centralized service-delivery approaches to benefit the poor that have led to a heightened awareness for the need of a participatory model. They are as follow: 1) the limited reach of the central authority; 2) the inability of the government to sustain necessary local action; 3) the limited ability to adapt to local circumstances and; 4) the creation of a dependency role. According to Yeung and McGee, there is a need for government agencies to rethink their roles as they relate to urban service delivery. Strategies and technologies that will require more involvement on the part of the community residents should be explored. There is also a need for decentralization of service delivery functions to levels closer to the community, which should be carried out in coordination with local officials (Yeung and McGee 1986). 2.2.2 Role of Non-governmental Organizations (NGOs) The relationship between development and politics have been increasingly under attack by NGOs for its creation of social inequities; environmental degradation; uprooting of rural communities, etc. The ability of NGOs to mobilize resources and gain political support, often with the assistance of international organizations, has made them one of the "fastest growing elements in the urban political and government situation" (Laquian 1992). Laquian cites the 12 search for social equity, and fight for causes of the urban poor, the underprivileged, minority groups, women and children, refugees, and newcomers to the cities as leading to the creation of NGOs. Nevertheless, in an era of decreasing financial resources and deepening poverty, both donors and national governments are looking to NGOs as a means of getting benefits more directly and cheaply to the poor than governments have been able to accomplish on their own (Korten 1987: 3). In response to the deficiencies of the traditional delivery systems, as previously mentioned, NGOs have sprouted to sponsor alternative delivery systems. In addition, many NGOs are becoming increasingly aware of their potential to command national attention and international funding, and of the need and opportunity to exert the necessary leadership in addressing people-centred development issues within a broad policy and institutional context. NGOs have repeatedly demonstrated their ability to help those most in need, and who have also been neglected and missed out by official aid programs (Clark 1991). Thus, they work in areas of extreme poverty, and many have managed to maintain a good working relationship with the communities of poor people they are working on behalf. It is often difficult for NGOs to successfully undertake projects as they can be faced with many obstacles, such as government indifference; corruption of officials; the dead weight of bureaucracy; the inefficiency of institutions; and hostile attitudes of the local elites (Clark 1991). The question that faces many of these NGOs according to Clark is whether they should learn to live with these obstacles 13 or should they try to remove them. If they ignore the obstacles, the issue of project long term sustainability comes to the fore. In Asia, there is a common perception, that NGOs "can be very effective in activating a bottom-up process of needs identification, project formulation, and implementation of grassroots development activities" (Getubig 1991: 46). However, for this bottom-up character of development to be maintained and strengthened there is a need to establish simultaneous links with the state as well as with the urban poor communities from the onset of any project (United Nations 1990: 10). The apparent strength of NGOs is their capacity for service delivery in poverty alleviation programs due to their small size, manageability, and freedom from bureaucratic processes that often delay or retard effective field level operations. Programs can be administered more effectively at this level than from the national level, as NGOs are closer to the poor they serve. In undertaking development work, it is often necessary to tap into the local NGO, so that they firstly introduce the outsider to the community, and more importantly they can act as a partner throughout the period of association. However, on the negative side, it is also important to note that the tendency for NGOs to be small and scattered, and lacking in institutional capabilities, human resources, and financial resources that the government commands, can also be inhibiting factors in assisting communities to achieve their full potential (Getubig 1991: 46). 14 According to Clark (1986), there is a need for "scaling up" efforts on behalf of NGOs. The challenge for NGOs is to seek ways to increase their impact, and to capitalize on the knowledge acquired from the lessons learned from their experiences of doing development work, without sacrificing the quality of their programs (Getubig 1991). Edwards and Hulme (1992) believe the strategy for increasing impact is for the NGO to expand or replicate their successful projects into other areas. In addition, institutional capacity of NGOs must exist in order for them to be involved in larger-scale projects (Salmen 1992). In some developing countries, the relationship between GOs and NGOs is very contentious. NGOs, in some cases, have managed to alienate government officials because of their success, "usurpation of government functions, or even because of their own ideological leanings" (Getubig 1987: 47). If this happens, it is often to the detriment of the urban poor. Korten feels that there is a need for the NGO to assume a "catalytic role involving collaboration with the government, and a wide range of other institutions, both public and private, to put into place new policies and institutional linkages that enable a self-sustaining local private initiative" (Korten 1986: 314). Thus in conclusion, there is a need for both government organizations and non-government organizations to cooperate and coordinate their efforts in a mutually supportive way. This combined relationship will ensure that the impact of projects and programs on alleviating poverty is maximized. 15 2.2.2i N G O s in Thailand Non-governmental organizations have played an active role in the Seventh Plan (1992-1997) of Thailand and will continue to co-operate in the Plan's implementation. However, although NGOs have existed in Thailand for the last three decades, their role has not been considered crucial to the advancement of Thai society. This is the first time that NGO involvement at this scale has been part of the national planning process. According to a Thailand country report to the United Nations on Environment and Development (1992), the change from an absolute monarchy to a constitutional government, along with the western influences after WWII have helped to promote social development in Thailand: hence the introduction of NGOs. Generally, NGOs in Thailand are most active in the areas of rural community development and working with youth and children. Initially, many of the early activities (in the 1960s) of NGOs were relief and social services projects. As the importance of NGOs increased, the nature of work became increasingly oriented towards rural development issues, encompassing health, literacy, economic and civil activities - as a better alternative to promote human development. It was during the 1970s that the NGO movement became more politicized, partly as a result of the 1970 student uprising in 1973. Students and academics established socio-political groups in order to demand radical reforms to social and economic policy and institutional structures. Through the 1980s, the "political radicalism of the 1970s had mellowed" (Thai Development Newsletter 1991), although NGOs continued to play a crucial role for the marginalized groups. However, the May 16 1992 revolution spurred the resurgence of more radical NGOs and the government responded in a way which blamed NGOs for the revolution, according to the director of the Thai Development Organization (an umbrella organization for NGOs in Thailand). The director believes that because of these developments, many people have become disillusioned with the role of NGOs, particularly the more radical left-wing ones. The NGOs of the last 10-15 years, according to Suntaree Kiatiprajuk of the Thai Development Support Committee, are beginning to make some impact on public awareness and public opinion concerning social and development issues. Kiatiprajuk argues that "they are emerging as a small progressive force for social justice and social change in Thailand" (Kiatiprajuk 1993). She believes that the government's emphasis on development is too economically driven, with limited interest on the environment, and even less so on self-reliance. NGOs, on the other hand, place more emphasis on supporting people and empowering them. In Thailand, NGOs are currently targeting: women, youth and children, hill and minority peoples, laborers, urban communities, handicapped people, rural communities, development workers and NGOs themselves. There is a wide range of NGOs in Thailand and they comprise many types of organizations (Thailand Report to UNCED 1992): (1) Grassroots NGOs and People's Organizations. Most of these are informal groups without legal status which have been formed on the basis of idealism and a commitment to campaign on a particular issue. These groups usually work closely with the poor and disadvantaged on issues concerned with social justice and people's empowerment. 17 (2) Student Organizations. Since the first emergence of student activism in 1973, student organizations have continued to play a role in the NGO sector in creating awareness about social and development issues. (3) National NGOs. These are the traditional NGOs concerned with specific aspects of development such as training, education and health. These organizations are formally registered with government as foundations or associations, most are professionally managed but often operate with very limited financial and technical resources. (4) International NGOs. According to the report, there were over 30 international or foreign-based NGOs operating in Thailand. These tend to be professionally managed organizations, with Thai administrative and field staff, but often with foreigners in senior management positions. Many of the organizations started working with refugees and have extended their activities into villages and/or urban slums. Their access to financial support is often good but projects operated by these NGOs may have a short life of three years or less. 2.2.3 Role of Community In successful poverty alleviation programs (PAPs), community residents are given due attention, their needs and views are respected, support is provided, but performance is also demanded from them (Getubig 1991: 38). There is a real need to empower the community residents to get them to deal with the issue of alleviating poverty. The people will need to be empowered in terms of information and knowledge, skills, awareness of the larger social, economic and political environment. NGOs may be able to help to some extent to mobilize and organize the poor, but essentially the desire will have to come from the residents themselves. Korten (1987) describes this process as capacity building in which the empowerment process enables the poor to enter the mainstream of development. 18 There are many barriers in communities that may impede effective community development work. Korten (1983) outlines some of these conditions as: 1) lack of appropriate local organization - where a local organization is perceived as being the channel through which the people can participate in the development and participation of a project; 2) lack of organization skills - where people have had too few experiences with running participatory organizations and thus consequently lack the skills to organize meetings, to reach consensus, elect appropriate leaders, maintaining records, or to handle organizational funds; 3) poor communication facilities - where the community is dispersed over a large area spatially and no telephones exist; 4) factionalism and differing economic interests and viewpoints exist in the community and; 5) corruption amongst the more powerful community individuals who take personal advantage rather than taking into consideration the welfare of the community at large. The practice of people-centred development practice emphasizes the need to strengthen institutional and social capacity support to obtain greater local control, accountability, initiative and self reliance (Korten 1987: 57). Given the opportunity to do so, the poor have tremendous innate capacity to help themselves and this has been demonstrated many times over (Getubig 1991: 20). To tap into their existing skills and productive capacity, they need credit for productive assets to complement their labour resources, access to markets and information, appropriate training and organization to support these activities. The government can play an enabling role while the people organize and mobilize their own resources. 19 Participatory Model Development initiatives in the urban poor communities should be taken by the people themselves who belong to the community, in the full knowledge of their problems and needs and not by an outside agency acting on their behalf. According to a U N document (1990), community participation is seen as an end in itself as well as a means. For example, it is not only a way of extending the government's limited resources and increasing project efficiency by sharing responsibility, but as an empowerment goal. By empowering the people, this will help to increase their control over resources and over the direction in which the project develops. This is an absolute necessary component of development as it is a process which will extend beyond the life of any particular project or program. A good project will plan this into the design so that once the NGO, GO or local governmental authority leaves, the community can be self-sufficient without having to depend on external staffing. Attempts to ensure participation must also allow for an understanding of functions and decision-making roles at the household level as well. One participatory approach is the community development approach which is composed of many stages (see table 2.1). According to Laquian (1969), the urban community development approach solves community problems effectively, while at the same time providing the urban dwellers the chance to use democratic decision-making in the process. It also has the advantages of being fairly inexpensive, allowing for the government to rely on personal, family and community efforts to meet the cost of solving urban problems, and assists in changing the attitudes, opinions, and motivations of people. The disadvantages are that it can not be 20 applicable in areas that are designated as future commercial areas and that it takes a long time to bring about results and changes in attitudes, because it works on and through people. However, it is absolutely necessary to include a participatory model from the onset of any project. Table 2.1 Stages of the Community Development Approach 1. Identification of common problems which must come from the people themselves as much as possible. 2. Pinpointing of community resources which if possible, when dealing with community problems must be met with resources that are locally available. 3. Analysis of alternative solutions. As with the first stage, the search for solutions should be made by the people themselves, with discreet guidance of the community development worker with an emphasis on alternatives that rely on local resources. 4. Organization of community efforts. The "community spirit" will be the main vehicle for programs and change. 5. Solution of problems. A community development worker has to keep in mind that the problems of a community are solved with the people's efforts and thus local resources must first be tapped into when solving problems. 6. Evaluation of program results is necessary by building the evaluation procedure into the planning and implementation processes (using the community leaders assisted by community development workers). (source: Laquian, 1969) 2.2.4 Role of Women in Gender and Development (particularly in health service provision) It is often women and children who are the most disadvantaged groups among in the urban poor. Limited access to education, health care, employment, credit, etc are only a few of the barriers that impede the development of women. In a recent Vancouver Sun article 21 (September 12, 1994), Jonathan Power wrote that "the secret key that unlocks the door on the impasse in Cairo at the world conference on population can be mouthed in one word: women". The article went on to say that there are a billion illiterates in the world, of which two thirds are women. Thus, Power (1994) believed that investment in education for these women would probably be the single most rewarding activity for any government at any level of development. Fitzpatrick (1994) adds that people are finally beginning to realize that development without raising the status of women is, first of all, not real development, and, secondly, it affects economic growth. The World Bank (Economist 1994: 25) also suggests that where women are excluded from secondary education, the average women has seven children; but if 40% of women go to secondary school, the average drops to three children. In addition to having fewer children, the women were found to take better care of them as well. At the national level the World Bank (Economist 1994: 25) found that educated mothers, by having fewer and healthier babies meant that the national bill for health care was quickly reduced. "With education and good economic opportunities, women can progress from a situation where they are triply disadvantaged - as poor; as women and perhaps, too, as single parents -to where their work has a triple multiplier effect - in the home, in society at large and, not least, in the development of the next generation" (Power, September 12, 1994). Power also made reference to the growing amount of research and evidence that a women's income and her degree of control over household spending is positively correlated with her children's nutrition and health. The Cairo conference suggested that specific measures for improving the lives of poor women should involve greater access to a broad range of health, family planning and 22 reproductive services, education and employment opportunities. However, the main emphasis according to Greenaway (1994), was that women should be "actively involved in the design and implementation of health and education programs". Empowerment of women was one of the final conclusions recommended at the close of the population conference (Greenaway September 15, 1994). According to Fitzpatrick, "giving women control over their lives is the key to averting a global population crisis" (Fitzpatrick, August 17, 1994). In all program approaches used there is a need to be gender-sensitive, and the involvement of women should play a major role in leading and implementing them. Research findings have indicated that women are often better credit risks; that for women financial stability and a steady source of family income are more important than business or making a profit; prefer a joint learning and sharing environment; believe in group solidarity and thus participate in community events more often than men and consequently use the community services (ie - healthcare and daycare facilities) more. Overall, it is the women who are more responsible for the functioning of the household, taking care of the children as well as being income-earners. They are forced to bear a much larger burden than that of men. The instances mentioned above are only a few of the reasons as to why there should be a specific emphasis on the role of women in development. The importance of health in development has been recognized in recent years, partly as a reaction against its neglect and other social needs in development policies in the 1950's and 1960's. Development policies stressed government investment in physical infrastructure. 23 However, it was soon recognized that development strategies aimed at economic expansion could not solve the problem of widespread poverty, social deprivation and inequity (Wong 1991: xiv). Thus, in search of alternative approaches to development, it was realized that the approach should not only be a human-oriented and basic needs approach, but also include the involvement of women. If looking at basic needs alone, one can see that women play a central role in daily activities. This is also particularly true to the health field, where women are the "natural and central figures for family health" (Wong 1991). In the particular case study that has been selected for analysis in this thesis, health was used as the entry point into the urban poor community. Wong (1991) believes that health appears to be an effective tool to mobilize women in development because men do recognize the importance of women in the health care of the family. Osteria (1991) goes on to say that women can have dual tasks - the responsibility for the health care of their families and contribution towards the formulation and solutions of health problems at the macro community level. However, required in any development project of this nature, is the need to sustain local action through developing local capabilities to operate and maintain the facilities put in place. In conclusion, there are four reasons mentioned by Osteria (1991) as to why women should be the focus in participatory research in health development: (1) mothers have the major task for the healthcare of their families and therefore the effective implementation of the community participation concept of primary health care implies their involvement at all levels of planning and management; (2) traditionally, women are the managers of local resources such 24 that their takeover of health services in the community will not detract largely from their normal activities; (3) relegating women to mere passive recipients of health services underutilizes human resources and stunts their development process; and (4) elevation of the status of women and recognition of their human rights and dignity demand great improvements in their health conditions, access to health resources, and particularly in decision-making at all levels. Thus, it was easier for the NGO to enter the site in the urban poor area without causing a threat to the position of the men in the community. Consequently, as it will be discussed in detail in a later chapter, it was the women who utilized the facilities more than the men. 2.2.4i Women in Thailand According to an AIT document (Shahand, Tekie and Weber 1986), women in Thailand, traditionally, have played as equally a supportive role as Thai men. Thai men have recognized the productive efforts and women's capabilities to shape family life and this in turn has led to a realization that women need to be treated equally. Even though a 1980 AIT study revealed that 69.9% of Thai women were illiterate, this was attributed more to attitudes, beliefs and traditions rather than from official policy (Shahand, Tekie and Weber 1986). Shahand, Tekie and Weber point out that according to the law, women in Thailand have equal rights in terms of entry to professions and are entitled to equal pay for work of equal value, on a basis equal to that of men. However, in reality, the role of women in the process of economic, social and political development has not, to date, been adequately recognized by Thai society (The National Economic and Social Development Board 1981: 253). 25 Isabel Kelly, past WID coordinator for CIDA in Bangkok, sums up Thai women's role in society in which the women are seen as the hind legs of an elephant. This suggests the partnership that exists between men and women and the need for cooperation between the sexes to achieve a better life. However, the majority of Thais believe that the primary role of the women is as a mother and wife, and then they are able to do anything else in terms of working outside the home. The Development Plans of Thailand (revised every five years) have been used by the government to pursue its development goals. For the past 20 years, at the national level, these official development plans have either ignored women or considered them mainly as wives and mothers. The increasing focus on the industrial sector within these plans has proven not to benefit disadvantaged people: particularly women, as they are being exploited for cheap labour. In 1961, Thailand began to develop its first five-year National Economic and Social Development Plans . The first two plans did not even mention women's development, thus assuming that women would benefit from development as any other group in the population (Thai Development Newsletter 1991: 12). Any programs that involved women were geared towards helping the family. It was only in the Fourth Plan (1977-1981) that women's development began to appear as an issue for national planning, a result of Thailand's participation in the United Nations' International Women's Year (1975) and the U N Women's Decade (1976-1985). However, although this plan aimed at improving the status of women and reducing inequalities between men and women, the training activities implemented in the rural 26 areas aimed at strengthening women's domestic roles as housewives rather than as farmers or workers. In the Fifth Plan (1982-1986) women were included as a special target group for the first time, as were children, youth and minority hill tribes. The problems that were identified as pertaining to women were: use of female labour; education; health and nutrition; and political aspects (ie - limited opportunities). Measures to solve these problems were the promotion of basic, formal and non-formal education, career training and free health services. The highest priority was given to women's organizations and income-generating activities. In addition to the Fifth Plan, a detailed and comprehensive twenty year Long-Term Women's Development Plan (1982-2001) was drawn up. The plan singled out problems and needs of women which were different from the needs of men. Women were categorized into groups such as women in agriculture, industry, the service sector, the informal sector, heads of households, migrants, etc. Objectives and key methods to sustain the efforts were established through policy recommendations included in the long-term plan. In the Sixth Plan (1987-1991), women were again not included as a special target group, and no direction was provided for women's role. The Plan only stated that the government would support women's participation in the decision-making process at the family, community and national levels and that it would protect women and child workers. 27 It should be noted that despite oversights of women in the national planning in Thailand, there have been some improvements in their lives. These changes can be attributed to social and political reforms and international pressure more than to planning. The national planning instead has had positive implications in making Thailand one of the fastest growing economies in Asia, and yet it is this shift from an agriculturally based economy to an industry and export based one which has had a negative impact on women's live. For Thai women, it was found that 80% of the female labour force were employed in the export-oriented industries, earning the country more than $6 million per year. The Bangkok Post (November 1990) stated that "the country's economic wonders and its double-digit growth rest on the shoulders of Thai women workers. 2.3 Catalysts for Community Development and Poverty Alleviation Programs The role of catalyst organizations can often achieve influence "far out of proportion to their financial resources or political authority" (Korten 1987: 11). Thus, both the design of the project and the role of the external/internal organizations are crucial to effectively deal with the issue of urban poverty. 2.3.1 Urban community development projects The design of the program as well as the activity selected, are critical if one wants to be effective in alleviating poverty. As mentioned before, with economic development as the main activity in dealing with urban poverty, the project(s) may not be successful. Instead, programs have to be geared to having a direct attack on poverty itself. With this in mind, measures such as social development activities (ie - health, education, housing or general community level 28 infrastructure activities - roads, wells, electricity, telephones, etc) should be done in consultation with the people to have any impact at all. According to Getubig (1991), successful projects include social and infrastructure development activities as supplementary activities which occur concurrently or at a later stage with the main or anchor activity being an income-generating one. 2.3.2 Entry into Community It is often difficult to know how to gain access into a community initially, particularly if one is an outsider. The community may be threatened by the presence of someone they do not know, especially if the motive(s) is unclear. Thus, as previously mentioned, it would help to enter through the local community leaders (informal and formal) or with the assistance of a local NGO. According to Laquian (1969), a number of entry approaches can be used to facilitate the entry of a development team. They include: 1. Entry through a research survey, because it helps to identify problems and the resources of a community, which in turn will help to base some of strategies for community development. 2. Have a service impact. The community will allow for easier entry if it knows that they can actually be helped. 3. Use of political officials. One can sometimes enter a community through the known political officials who have a following in the place. 4. Use of traditional government workers (ie - teachers) can be used because of their familiarity with the place and the people. 5. Use of social activities can be encouraged (both traditional activities and new ones). 29 6. Economic appeals. It will be easier to enter a community if one can expose the community to different ways of helping it improve their means of livelihood (ie -dress making, tailoring, small business ventures, etc.). 7. Appeal to the main community interest. It is best to study the main problems of the community and to help or at least sympathize with the people in this respect. 2.3.3 Consolidation of Efforts Consolidation or strengthening the community efforts must be an underlying goal for any agency involved in community development work. Getubig (1991) believes in the availability of opportunities to the poor to build their capacities to overcome their disabilities, and to initiate and manage development actions for life improvement is central to any process of poverty alleviation. Capacity building in this situation is defined as an empowerment process which enables the poor to enter the mainstream of development (Getubig 1991). Capacity building activities as defined by Korten (1987) can take many forms: 1) building a critical awareness of the community's existing reality, and help to gain an understanding of the underlying causes of poverty; 2) building participatory organizations, over which the poor have effective control; 3) helping the community to mobilize its own resources so that it can initiate its own changes; 4) providing technical and managerial skills; 5) providing legitimate entitlements and helping to obtain access to external resource flows and; 6) building capacity to sustain development initiatives on a self-reliant basis. The role of external agencies (NGOs, government, and the private sector) should be one of assisting the poor in building their own capacities, through a two-way interaction process. 30 Their role can be as "animators, facilitators, change agents, catalysts or community organizers and using a non-dominant and non-bureaucratic mode of interaction" (Getubig 1991: 88). Algeros (1988) refers to the consolidation of efforts as his third stage of community sustainability, after the stage of the NGO' birth and the crisis stage. In the third stage, the NGO devotes its resources to establishing a sound management and administrative base. Personnel policies are institutionalized, financial management systems are established, and priorities are given to long-term planning and coordination. 2.3.4 Community Organizations According to Yeung and McGee (1986), a precondition to participatory urban service delivery is the existence of community organizations and leadership. The reason for this need is because the community itself must be able to plan together and devise a program of action that can be undertaken and maintained by the residents. Ultimately, "the more organized the community, the better equipped it is for participating in development" (Yeung and McGee 1986: 98). In many of the urban poor communities, such as Nong Khaem, no community organizations exist. Mitlin and Satterhwaite (1992) believe that NGOs and external agencies working in such areas have to get involved in an attempt to establish a community organization. Thus, community organizations are being created in the urban poor areas as a response to their basic needs not being met. Some are created at the local level, while others are at the 31 neighborhood level. The main purpose of these associations is to give a voice to the needs of the urban poor, to their collective interests and rights. Since many of the community residents are self-employed, usually within the informal economy, a certain degree of flexibility and availability of time exists for organization to occur. Though many communities do not have official local community associations/community based organizations, it is extremely important to recognize the existence of informal groups. This should be of particular interest to community development workers and outside organizations, when entering an urban poor community. For many new arrivals in an urban poor community, being familiar with the neighborhood and participating in the local organizations is very important in order to become a part of that community. In general, these local community organizations are more effective in organizing self-help services and infrastructure construction than if they have been brought together on their own initiatives rather than due to officially sponsored development programs. Community participation can enter into play in the decision-making process as to where to locate faucets, types of structures for communal toilets, etc. Community meetings with the help of outside facilitators, if needed, may aid to identify the priorities and take account of the local resources that can be utilized. Role of community leaders 32 Another dimension to consider when dealing with the issue of alleviating urban poverty, is the role of the community leader(s). There is a need for community organizations to produce internal leaders who can command the confidence of fellow residents, and have the facilitation skills to coordinate group actions (Getubig 1991). This is extremely important in order for the community to decrease its dependence on external agencies. It is equally important to rely on leaders to assist in entering into a community as much as it is to rely on the role of community organizations. Thus it would be useful to have a leadership survey from the onset to help identify the leader(s) and in turn this will enable the community development workers to get a profile on their characteristics (Laquian 1969). At the state level, it would be advantageous to get government support for the community lead structures and to keep leadership on an democratically elected basis (Yeung and McGee 1986). By obtaining an assessment by the community leaders of the overall needs of the community, basic urban services, with the aid of local resources, can be identified. However, there is also a need to recognize the dual existence of both formal and informal leaders within a community. There is always the fear that "working through the appointed leaders may inhibit the development of other persons with leadership potentials (Laquian 1969: 117). In other words, although the formal leader may be the person that the local government deals with, the actual recognized community leader may be the informal leader appointed by the people themselves. 33 2.3.5 Transfer of Responsibilities to Community In working with community development projects, there is a need for the NGO (or whomever) involved to be aware of the necessity to secure community ownership over the project for long term sustainability. If the community remains detached from the project and is not involved in a participatory role from the onset, then the long term survival of the project is at risk. The NGO entering a community that lacks the social infrastructure or a solidified community organization, should play a catalytic role in encouraging involvement in the project. Slowly more of the responsibilities should get shifted to the community, with the role of the NGO becoming increasingly that of an external advisor to the project implemented. 2.3.6 Self-reliant development (sustainability) According to Korten, NGO aid efforts to deal with poverty alleviation have gone through three generations, "with each subsequent generation of thought and action bringing to bear a longer time perspective and a broadened definition of the development problem" (Korten 1986: 313). The first generation approach was relief and welfare; the second - small scale local development, which addressed the need to increase the capacity of the poor to meet their own needs with their own resources; and the third generation being a "sustainable systems development" approach (table 2.2). The sustainable systems development approach realizes that "sustaining the outcomes of self-reliant village development initiatives depends on systems of effectively linked public and private organizations which integrate local initiatives into a supportive national development 34 system" (Korten 1986: 314). Clark (1991) argues that the more conscientious NGOs have come to realize as well that their projects by themselves can never hope to benefit more than a few select communities, and for these projects to be sustainable in the future there is a need for local public and private organizations to link in a coordinative way. Yeung and McGee believe that the existence of a coordinative structure (comprised of community groups and outside resources -mainly government representatives) will be able to "convey information and transmit messages to and from the community and act as a catalyst for change" (Yeung and McGee 1986: 100). Table 2.2: Three Generations of NGO Development Program Strategies 1st Generation 2nd Generation 3rd Generation Defining Features Relief & Welfare Small-scale self reliant local development Sustainable Systems Development Problem Definition Shortages of goods & services Local inertia Institutional and Policy Constraints Time Frame Immediate Project Life Indefinite, Long-term Spatial Scope Individual or family Neighborhood or village Region or Nation Chief Actors NGO NGO + Beneficiary Organizations All Public and Private Institutions that define the Relevant system Development Education Specific targetfe.g. starving children) Community Self-Help Initiatives Failures in Interdependent Systems Management Orientation Logistics Management Project Management Strategic Management (source: Korten 1987) 35 NGOs committed to the third generation strategy must develop disciplined organizations managed by well-trained and highly motivated professional individuals (Korten 1986). According to Korten, to develop these capacities, the NGO must make a commitment through: 1) sending key senior staff for advanced management training; 2) developing collaborative relationships with groups that have capabilities in related social and policy analysis; 3) documenting and critically assessing third generation efforts to strengthen learning from own experiences; 4) conducting strategic assessment workshops with NGO staff; and 5) participating in informational exchange workshops with other NGOs. Korten argues that the "more an NGO embraces the third generation strategies, the more it will find itself working in a catalytic, foundation-like role rather than an operational service delivery role" (Korten 1987: 6). To undertake a catalytic role there are two necessary qualifications: 1) the organization must have experienced professional staff who are able to combine in-depth country knowledge, professional credibility and facilitation skills; 2) the organization must be able to remain flexible and be quick in securing funds (through small and medium sized grants) for activities as required (Korten 1987). In order for the community to sustain its initiatives, horizontal and vertical linkages need to be established (Korten 1987). Korten argues that even though communities can do a lot on a small scale to improve their conditions, there comes a point when the "feasible agenda of autonomous organizations gets exhausted" (Getubig 1991: 64). Linkages amongst other groups, 36 with the government and other agencies to derive support and assistance for the communities' activities are essential. 2.4 Summary It is apparent that to deal effectively with alleviating urban poverty is not an easy task. There needs to be real commitment on behalf of the players involved (ie - GOs, NGOs, and community) to tackle the problem in a jointly cooperative and coordinative effort. However, the underlying approach should attempt to always maintain a participatory/people-centred approach using the local resources where available. According to Laquian (1969: 159), it is the idea of "democratic decision-making and personal participation so central to community development that makes urban community development so difficult". Poverty alleviation programs should be designed, implemented and managed in a manner that suits the characteristics of the poor, and not the needs of external agencies (be it government or NGOs). Critical design features such as effective targeting and selection; organization and capacity building; accountability, and fostering of genuine participation by beneficiaries should be incorporated into the projects. "The cardinal principle in poverty alleviation is that the poor are to be empowered, not to be hampered" (Getubig 1991: 38). 37 CHAPTER 3 H E A L T H INTERVENTION AS A C A T A L Y S T FOR COMMUNITY D E V E L O P M E N T 3.1 INTRODUCTION With Bangkok's metropolitan population expected to climb to 12 million from its current level of six million by the year 2000, dreams of a better housing situation are not likely to be realized (Bangkok Post June 26, 1988). Urban authorities who have been trying to persuade many of the squatters to leave the inner city have been faced with constant refusal by the urban poor: for most often their source of income is derived from the city's centre. Though Bangkok's source of population increase can not only be attributed to rural migrants coming to the city, it is one reason why the city is growing rapidly. Bangkok is still perceived by rural migrants as the place with employment, health care and education. But an increasing number of migrants are faced with failure and depression in the heart of the city. According to the National Housing Authority (NHA) of Bangkok, over 225,000 households or 1.1 million persons in Bangkok live in slums. This population comprises 14% of the total BMR population, estimated at 8.2 million (Yap 1992). Most of the slum families have a rural background, with 59% of the heads of households having been bom outside of Bangkok. However, a majority of household members (65%) were bom in Bangkok and thus it is understandable why some of the slum dwellers protest and make it clear that because they are well established in Bangkok and have permanent employment, they have a right to stay and not be evicted (Yap 1992). 38 In Thai society, where open conflicts are avoided as much as possible, land owners often stop collecting rent from the slum dwellers to signal their intention to terminate the lease contract, although they may wait several years before they actually request the dwellers to leave (Leckie 1990). This is intended to provide adequate time for slum dwellers to prepare for the eventual eviction. The slum population, in return, often accept that their stay is only temporary and thus agree to leave when asked, without protest. If the slum dwellers disagree, fires become very common in an attempt to move people off the site (Yap 1992). Thus, as land prices increase, "what was once undeveloped, non-desirable land, has increasingly become a battleground between the poor who call it home and private landowners who wish to exploit the land for all of its economic potential" (Leckie 1990). The NHA estimates that in the period 1974-1986, more than 200 slum communities were evicted (Islam and Yap 1989). Without legal guarantees for housing rights, there is little chance that slum conditions for the dwellers in Bangkok will improve. In this chapter I will attempt to provide a cursory glance into one of Bangkok's poorest slum communities. This chapter will describe the site that was chosen for examination by the researcher in Bangkok, Thailand. The focus will be on the specific site, and background information will be presented on the formation of the Nong Khaem Mother & Child Health Project. 39 3.2 Case Study - Nong Khaem Mother Child Health Project 3.2.1 Project Background The project site is the Nong Khaem garbage dump, which is located in the western side (Thonburi) of the Bangkok Metropolitan Region: one of Thailand's 73 provinces (see Map 3.1). The garbage dump is the second one located within the Bangkok Metropolitan Region (BMR), and services the Thonburi side of the region (see Map 3.2). The other dump, known as the Onnut garbage dump, is located east of the Chao Phraya River and services the rest of Bangkok. The community of approximately 2,500 residents (600 families) on the site, is physically located to the east of the dump. The garbage dump, health clinic, daycare facility, and parts of the residential areas are located on government land (see Map 3.3 - Nong Khaem Site Plan). The remaining residential community is located on privately owned land, where the dwellers are renters, squatters, and a few owners. Figure 3.1 indicates the respondents land title. Forty-one percent of the respondents were residing on land for which they paid no rent. Of the eighteen respondents who were squatting, eleven (61.1%) were from Northeast and Central Thailand: two of the poorest regions in the country. The health clinic which was servicing the community before the establishment of the new health facility is located 6 km from the community and the nearest government hospital (Siriraj Hospital), is 20 km away. Aside from these two health service centres there are several private hospitals and clinics which are located within a distance of 6 km but are too expensive for the community dwellers, in terms of both transportation costs to and from the facility and actual medical costs. 40 Map 3.1: Districts of Bangkok 41 Map 3.2: Location of Existing Disposal Sites in B M A (source: Yap 1992) Figure 3.1: Respondents Land Title Leasee 42 MAP 5.5: NONG KHAEM - SITE PLAN Since February, 1987, the Foundation for Slum Childcare (FSCC) with support from the Bangkok Metropolitan Administration (BMA) and funding from a French organization, has been running a mother and child health program in the Onnut garbage dump community which is also located in the BMA. Through the experience and the success of this project, FSCC applied for funding from CIDA's Canada Fund to set up another health clinic in Bangkok's second garbage dump community. This is a case of what Korten (1983); Clark (1992) and; Salmen (1992) define as "scaling-up" the impact of NGOs. In this case, the vertical expansion into Nong Khaem was geographical, whereby the NGO replicated the success in one area into another slum community. The aim of the project initiated by the FSCC was to establish a public health centre in one of Bangkok's most impoverished areas. Before submitting a proposal to the Canada Fund, a survey was conducted of the health of mothers and children in the Nong Khaem community. The results of this survey forced the NGO to take a further look into the problem facing the children under the ages of five, as many of them are left alone during the day while the parents are working. The proposal to set up both a health clinic and a daycare facility was submitted to the Canada Fund in 1989 and was accepted almost immediately. The Canada Fund was established to assist NGOs in undertaking community development projects in Thailand. In 1992, the Canada Fund also funded the establishment of a playground facility ($4,990 Cdn) on site, located between the two established facilities. 44 3.2.2 Community Profile Demographics The community is separated into one big cluster of houses with several small ones surrounding it. Though recognized as one community, it is actually further divided into five sub-communities: Langwat, Issan, Jutsan, Sutsui, and Sammakii. Amongst the sub-communities there are some noticeable disparities in the levels of poverty. Issan community, divided into Soi Issan 1 and Soi Issan 2 (soi meaning street), is the poorest sub-community. The name itself -Issan - is used as another name for the Northeast region of Thailand, indicating the place of origin for the people in this community. This agricultural area suffers the most from both droughts and floods, thus forcing the people into Bangkok to seek a better life or at least a livelihood to support family members who remain in Issan. Many of the people from Issan return home during planting and harvesting season. Issan community is the most transient and according to many of the NGO staff this has caused some problems amongst the other more permanent dwellers. One of the NGO nurses mentioned that the difficulty in establishing a community organization lay in the fact that the community was divided into two groups: 1) permanent and 2) non-permanent. Nong Khaem community is comprised of approximately 46% male and 54% female, with 95% of the population being under the age of 50. In terms of the length of residence, 51% of the population moved into the community during 1987-1990 (1990 was when the NGO conducted an initial survey). This is attributed to the feeling of a low sense of community, as these residents do not look at the site as being "home". It was interesting to note that most of the 45 squatters were found to be recent arrivals, with 83.3% of them residing in Nong Khaem for less than fifteen years, and 61.1% residing in Bangkok less than twenty years (see figures 3.2 and 3.3). This indicates the relative young age of the community, and hence one reason why the community has not managed to establish an effective community organization. Of the forty-four respondents interviewed, only 15 (34%) were born in Bangkok; 2 of whom were born in Nong Khaem (figure 3.4). Another important concern revealed through the questionnaires was that when respondents were asked how long they planned on staying in Nong Khaem, 34% answered until evicted; 27% said for a long time; and 11 % were uncertain. These types of responses indicated the relative uncertainty pertaining to security of tenure. Van den Bosch, the project manager and physician, believes that if the people had security of tenure, then a community organization would naturally ensue. When asked where they would go if forced to move from the place, 61% of the respondents were not sure. Again, this indicates the instability that many of the residents of Nong Khaem are faced with. Physical Conditions Sanitation conditions in Nong Khaem were poor with 39% of the houses having no toilets, and though water was available it was extremely expensive (it was more expensive than if the BMA was to provide it). The NGO survey revealed that 88% of the residents purchased piped water at 10 Baht a jar, whereas in the government serviced areas, the residents paid approximately 4 Baht ajar. One estimate is that the dwellers spent over 25% of their income 46 uraBifx Suofsj in A B J S J O q^Snaq ajnSi j 81? Percentage of Community Residents Figure 3.4: Birthplace of Respondents East Nong Khaem / 1 / South North Northeast Bangkok Central 49 on water and electricity. Houses were constructed of whatever materials (metal, cardboard,plastic, etc) were available on the site, and often they could not withstand the flooding from the monsoon season. The streets also got severely flooded and muddy in the residential areas. This was one of the most often heard complaints. Upon visiting the garbage mountain for the first time, the researcher found the stench unbearable. Children of all ages were assisting their parents in scavenging through the garbage. By the numbers of people on the mountain (often as high as 800), there appeared to exist a small community. Conditions were grim and in some instances fires broke out on the dump leading to numerous injuries. Some of the community members would remain on the mountain for up to three days before returning to their homes. Most of the dwellings were located to the east of the garbage dump. Socio-Economic Conditions The garbage dump provided the slum dwellers with their economic means of survival. According to Yap (1992), Nong Khaem received 1,610 tons of waste per day. The waste was comprised of household waste, business waste, and infectious hospital waste (table 3.1). Often the dwellers would work in teams of 10 to 12 when scavenging through the garbage. A 1990 study by United Nations ESCAP revealed that the total daily tonnage of recyclable garbage collected by the waste pickers is estimated at 286.03 tons, which is approximately 5% of the 50 Table 3.1: Waste Dumped at Disposal Sites Year BMA Area Ramlntra On Nooch Nong Khaem 1 2 1 2 1 2 1986 3,738 56 871 217 1,202 28 1,364 1987 4, 190 31 1,584 158 1,340 14 1,063 1988 4,225 1 1, 190 263 1,051 139 1,581 1989 4,085 125 328 187 1,276 83 1,529 1990 4,340 0 0 139 1,214 52 1,652 Units: Tons/day Note: 1 = Compost Plant 2 = Disposal S i t e (Source: Yap, 1992) total garbage collected by the city (Yap 1992). The amount collected by the scavengers in Onnut and Nong Khaem varied between 50 and 150 kg per person per day. The daily income of the scavengers varied between 30 and 300 Baht ($1.50-$ 15.00 Cdn) per person (NEA/BMA 1989). The initial survey conducted by the NGO indicated that people in the community are extremely poor with 78% of the families living below the poverty line, receiving 3000 B ($150) per month per family. Based on the researcher's findings, 63.6% of the respondents indicated that the household head income was below the poverty line (see figure 3.5). Almost all of the residents lived off the garbage dump in one way or another according to van den Bosch. The residents were involved in collecting garbage, processing garbage, or driving garbage trucks. The recovered material was sold to small scale recycling shops located around the disposal site. Refuse collection vehicles would also stop in front of the shops to 51 9UI03UT p B 8 H pioqasnou ^pnuopv :c/*£ aangij Figure 3.6: Place of Work Unloads Garbage Tailor Sells Things Scavenger Prison Guard Metal Worker Money Lender Housewife Health Care Worker Factory Drive BMA Truck Daycare Worker BMA Worker Not Working 53 unload the pre-sorted materials (plastics, bottles, tires, metals, etc). In 1990, it was estimated that 2,000 scavengers were working at the Nong Khaem dump site. Figure 3.6 provides someindication as to the respondents and their spouse's place of employment. By far, scavenging garbage was the most common form of work. Other job related activities were identified as unloading garbage, selling things, driving BMA trucks, and working for the BMA. The majority of the respondents were women (68%), and were more inclined to be working at the garbage dump; as housewives; and as health and day care workers. The men were found to be mainly employed as drivers for the BMA; at the factories and also at the garbage dump. The family structure in the community was breaking down rapidly, as many of the men were involved heavily in gambling and drugs; did not share in the responsibility of raising children; and sometimes did not make it to work. In addition, 80% of couples were informally married (not legally recognized) and a man often had more than one wife. As this project was initiated with an emphasis on women being the main agents of change for the community, a recent attempt had been made by the NGO in 1993 to encourage fathers to take an active role in the parenting of children. Field trips such as camping, barbeques, and going to the beach took place where all the members of a family were brought together with the NGO staff. The NGO arranged for workshops for the fathers and mothers separately while the children were looked after. The results were extremely positive in that the rate of participation was high. It remains to be seen what long term impact these trips have had on the family unit. 54 The NGO revealed that amongst the mothers who responded to the survey (NGO survey 1989), that 63% had less than four years of formal education: of these female respondents 15% were found to be illiterate. Van den Bosch mentioned that one of the reasons why so many of the women got pregnant at an early age was due to their low levels of education. Twenty-eight percent of the mothers interviewed were less than twenty years of age. As was cited earlier in this thesis, the World Bank suggested that where women were excluded from formal education, there was a positive correlation in the numbers of children they had. Health Conditions The poor health conditions in the Nong Khaem garbage dump community compelled the NGO to look at this site as setting up a health care and daycare project. The scavengers, as pointed out by Dr Anne-Marie van den Bosch, the project manager and doctor for the site, suffered frequent cuts from the jagged edges of broken glass and torn metals, cuts which often turned septic. Most of the children had not received the proper vaccines and only 29% had been vaccinated with the DPT vaccine in 1990. There was also a high incidence of mild malnutrition amongst the under-fives, and 3% were found to be significantly malnourished. Overall, previous interest had not been shown in the establishment of basic public health policies or preventive health-care measures in the community. 3.3 PROJECT INVOLVEMENT 3.3.1 Role of Funding Agency - Canada Fund 55 The Canada Fund is a Canadian Embassy administered fund with the general objective of "assisting non-governmental organizations to carry out small but innovative development projects within Thailand" (Canada Fund document 1990). The funds which annually amount to approximately $500,000 come from the Canadian International Development Agency (CIDA). The guidelines are that the projects be either rural or urban in nature and be involved in agriculture, education, health, income generation, forestry, fisheries, or human resource development. Generally, the Fund will approve projects which are considered to be "grass-roots" in orientation and which directly benefit the poor. Approved projects, of which there are approximately 40 per year, can be funded for one to two years. Through CIDA's Canada Fund, the Nong Khaem project was able to secure funds for both the health clinic and the daycare facility initially, and then some minimum support for the playground. The Canada Fund was asked to fund a low cost centre, equipment and staff in the first year, and take care of normal program costs in the second year. In the first year, 455,000 B ($20, 875) was provided while in the second the Canadian government provided an additional 330,000 B (15,100). The coordinator of the Canada Fund, Jake Buhler, perceives the Nong Khaem project as one of the most successful projects to be funded. At the opening ceremony, March 15, 1990, of the health care facility, Mr. Smith (Canadian Ambassador to Thailand) made the statement that "today we have an outstanding case of human resources meeting human need. The Foundation for Slum Child Care is an example of a Thai vision harnessing local staff and a modest budget to tackle a local problem". 56 Though the project was launched in 1990 with the assistance of CIDA funds, Medecins Sans Frontieres (Belgium) and the Ministry of Public Health also began to contribute to the project from 1992. The Princess Mother's Fund also contributed 1 million baht ($50,000 Cdn) to help establish the daycare centre, and Save the Children Fund supplied enough support to cover 60-70% of the running costs for the first three years (1992-1995). 3.3.2 Role of Nongovernmental Agency - Foundation for Slum Childcare (FSCC) The NGO for this project is the Foundation for Slum Childcare (FSCC). The Foundation was established in 1981 by Prateep Ungsongtham. Prateep, also born and raised in a slum (Klong Toey) was awarded the Rockefeller Foundation Outstanding Youth Award for her work in the slums. It was with this money and some private Thai donations which led to the establishment of the FSCC. The Foundation is committed to ensuring that slum infants from birth to 3 years receive proper care; to providing assistance in the field of public health and hygiene to infants; and to educating mothers and pregnant women in slum areas. The Mother and Child Health program at Nong Khaem is only one of the projects currently being undertaken by the Foundation. Other projects include a community child development program; a rural child development program; a child development centre and a milk and supplementary food program. The FSCC objectives for the Nong Khaem project were three-fold: 1. to set up a health care program with participation from the community and with maximum emphasis on community education, with the aim of enabling the dwellers to take more responsibility for their own health. 57 2. to provide the community with a small community based health care facility giving the following services: family planning under proper medical surveillance a clinic for children under the age of five with an emphasis on prevention, growth monitoring and mother education post natal care and counselling on caring for newborns curative care for minor medical problems and community eduction in drug use 3. to improve home sanitation The NGO also played an advocacy role on behalf of the community with the local government, in which they were able to receive access to land to set up the facilities (health clinic, daycare facility, and playground). Salmen (1992) referred to one of the NGO strengths as being one of coordination between the government and the community to obtain basic services for the poor. According to Salmen (1992), governments are particularly responsive in meeting demands dealing with preventative health care and family planning. Within the program, the target population was (1) women of childbearing age; (2) pregnant women; (3) families with young children and (4) children under the age of five. Although the FSCC conducted a survey prior to setting up the facilities, the community had had no previous contact with any other NGO. The researcher's findings indicated that, of those interviewed, 66% had been consulted by the NGO in deciding if they wanted a day care and/or a health care facility. The NGO maintained a participatory approach and employed and trained community residents as health care and day care workers. The majority of the respondents (68%) stated that they did not prefer anything else to the day care and health care facilities. Of those who answered "yes" (32%) to preferring something else, the preferences mentioned were a public telephone, a cooperative store; and a job training centre. Van den 58 Bosch assisted in setting up a cooperative store in the Onnut garbage slum community, however due to some squabbling of who was to manage the finances, the store was never opened. Van den Bosch felt that the community wanted her and the NGO to play an active role in the managing the store and she felt that this should be left up to the community. It became apparent that the Onnut community lacked the self-initiative and resources to work collectively in other to establish the cooperative. 3.3.3 Role of the Local Government - Bangkok Metropolitan Administration (BMA) The Bangkok Metropolitan Authority is the local municipal government for the province of Bangkok. The BMA's main role is to administer public infrastructure (education, health, sanitation, electricity, water, etc) to the people residing in the province. Within the hierarchy of the BMA a Community Development Department does exist, in which the department is responsible for the planning of slum improvement, housing management and vocational promotion and development. According to Wina Chantaphet, the director of the Department, the role of the department is that of providing technical knowledge to the community residents; planning and supporting other agencies working on community development initiatives (ie - the National Housing Authority); and dealing with the social concerns of the people in Bangkok. An organization chart of the BMA can be seen in the figure 3.7. According to Chantaphet, the BMA organization chart encompasses both a top-down and bottom-up approach. The top-down approach is one in which the Community Development Division is responsible for the planning of the strategies to be used on how to approach the communities at the local level. 59 The division then works in cooperation with the district community workers to arrive at an action plan to be implemented at the local level. From the bottom-up perspective, Figure 3.7: BMA Organization Chart BMA ORGANIZATION C H A R T Governor of BMR Committee of Community Development Sub-Committee GOs Members of Governor's Committee Community Development Dept ; _ • Civil Engineering Dept • Education Dept • Sanitary Dept • Social Welfare Dept • Health Dept • Policy & Plan Dept NGOs Districts of BMA (36) j Representatives from Districts Community Based Organizations > Source: BMA Chart 60 the CBOs are asked to survey their own needs (through conducting a Basic Minimum Needs Data Survey, initiated by the BMA), and once their priorities are established they are to relay the information to Community Development Districts through the appointed community development workers. The community leader (usually the formal leader appointed by the BMA) also works in cooperation with the community workers to establish the needs of the local residents. In the Nong Khaem community many of the dwellers are residing on land owned by the BMA. Because they are not legal residents, the dwellers are not recognized and have no access to public education or other services provided by the government. In Thailand, a resident must have a fixed address to be recognized as being legally married, have access to education, receive water and electricity, etc. This is the dilemma faced by many of the inhabitants who are occupying land illegally. In turn, they are limited in terms of having access to public facilities. This is an area where there needs to be further cooperation between the local government and the community. For the Mother & Child Health project, the BMA provided the land for both the health care and daycare projects to locate. The BMA also provided family planning materials, vaccines and patient records. However, through the interviews, the researcher became aware of the limited contact that the BMA had with the community itself. Instead, they communicated to the community through their appointed representative (the formal leader), who himself had been an employee of the BMA for many years. Ninety-three percent of the respondents in the 61 questionnaire indicated that they never had had any meetings or contact with the BMA. The findings have indicated that there is a need for the local government to take a more serious role in the provision of services (education, vocational training, infrastructure, etc) to this impoverished segment of the population. This issue has been documented repeatedly by many researchers involved in community development work (Korten 1987; Yeung and McGee 1986; Clark 1991). 3.3.4 Role of the Community According to van den Bosch, the program was purposely kept flexible, allowing for maximum input from the community and adapting to the needs of the community. For example, working hours for the clinic and daycare facility were defined after consultation with the community. The health care and day care workers were residents of the community and played an essential role. The health care workers responsibilities included: 1) taking vital signs and giving simple care; 2) an intensive home visit and community education program; and 3) encouraging feedback from the community, allowing for flexibility to adapt programs to the actual needs of the residents. The community workers, selected from the community, served as informants on the happenings within Nong Khaem. For the NGO they were an extremely important link with the rest of the community, especially as the workers were found to be trusted and respected by the other community members. The community residents were able to express their concerns to the health workers and this in turn was communicated to the NGO staff. A United Nations 62 document has indicated that the rationale behind employing community health workers was essential in achieving better health standards for all (Walt 1990). These workers could be trained in a short time to perform specific tasks and it was also seen as being advantageous if the health workers came from the community in which they resided (as was the case in Nong Khaem) for they then have the support and trust of the community. In the case of Nong Khaem, the role of the community workers will be essential in the functioning and maintenance of the facilities to be sustained over the long term. Before the FSCC became involved with the Nong Khaem community, there had been neither any governmental nor non-governmental involvement. One of the reasons why NGOs had not taken an interest in the community was that they considered the community to be located too far out of the way to reach in terms of access. As many of the dwellers were recent arrivals to Bangkok, it was even more difficult on them to cope with their new environment without any external support from the community. People worked for their own personal survival and community sense was already low before the entrance of the NGO. Van den Bosch mentions that in the beginning the NGO was not fully accepted and the community criticized that not enough medicine was being provided. The NGO was attempting to educate the community on preventative medicine and wanted the community to learn to manage their own health needs. Gradually the community has now come to trust and rely on the efforts of the NGO staff and the community health care workers. 63 Most of the questionnaire respondents (91%) in one way or another helped their neighbours in the community. Common responses were helping their neighbours with house construction; festivities; child care; household chores and developing the community (ie -building roads, preparing land, water drainage, and physically cleaning the community). The festivities which were most often celebrated with one another were New Years (64%); Songkran - Thai New Years (41 %); and making merit together (41 %). When the respondents were asked about their perceived role in the community, 86% indicated that they were members of the community. Ninety-three percent answered "yes" to living in a close-knit community. However, it is interesting to note that 89% indicated that there was not a community organization (formal) in Nong Khaem. Since many of the respondents (82%) worked five days or more, leisure time was limited. The most common activities in their leisure time were visiting friends and family (39%); completing household chores (34%); sleeping (25%); and watching television (18%). An overwhelming 86% responded "yes" to wanting to play a future role in the development of their community. By far, the two reasons most cited as to why they wanted to play a role were: 1) to help develop the community (68%) and 2) to create a better/comfortable living environment (68%). However, when the interviewees were asked what specific problems they faced in the community, it is interesting to note that the most common response was "we do not face any problems" (41%), and yet this community was recognized as being one of the poorest in Bangkok. Perhaps, this response could be attributed to a lack of future vision; lack 64 of a community organization which could act as a vehicle to promote change and foster development; or low expectations of any development to occur: sense of hopelessness. Community Leadership As mentioned previously, the formal leader had been appointed by the BMA. At the time of the researcher's interview with the formal leader, he mentioned that his appointment was almost finished, and he felt that he was not going to apply again for leadership. He expressed his discontent for the lack of support he received from the community. The leader owned the local convenience store in the community (in Soi Issan), where he sold his merchandise at a 40-60% mark-up. The community residents had no choice but to purchase items from him, for they did not have the time to travel to the local market to buy their products. Because public transportation was located off the main road (Phetkasem Road), the residents had to pay more than they would on public transit to the local motorcyclists (known as 'soi boys'), who drove the residents to the main road. In addition to his appointment with the BMA, the formal leader was both a money lender for the residents, where 20% was added daily in interest, and the manager on top of the garbage mountain. He made sure that the scavengers remained in their designated areas, and took care of the fires that broke out. Thus the leader managed to survive off the desperate situation of the other dwellers. The formal leader felt that he did play an important role in the community. He stated that residents did approach him about their personal problems, and that through his relationship 65 with the local authorities (BMA and the NHA), he was able to improve the situation of the community. At the time of the interview the leader was in the process of negotiating a public phone to be established. Because the formal leader was not recognized as truly representing the concerns of the people, the NGO only had limited contact with him. Instead the NGO relied more on the information that was obtained from the health workers, who helped to identify the informal leader, to whom the people looked more to that the formal leader. The informal leader lived in the community furthest away from the main road (see Map 3.3). He was more recognized than the formal leader, and the community often approached him with their personal problems. However, the problem lay in the fact that he was not recognized by the local authority, and thus lacked the decision-making power which was necessary to advocate for changes within the community. 3.4 Summary As outlined in this chapter, it is apparent that any form of community development work involves a number of players, in which each role has to be recognized and appreciated. In the Nong Khaem Mother & Child Health Project, the major players are the community itself, the NGO, the BMA and the funding agency - CIDA. Securing entry into the community was obtained through using the provision of primary health care as the intervention catalyst. Women were considered to be the main targets by the NGO. It seemed a natural process in this project to combine health and women in the community, as women have traditionally played the role 66 as primary care givers. This combination was one reason why this project has been considered to be successful in meeting the needs of the urban poor and in assisting to effectively deal with poverty alleviation. 67 CHAPTER 4 T H E RESULTS O F PROJECT INTERVENTION: COMMUNITY VIABILITY AFTER NGO/CIDA ASSISTANCE? 4.1 Introduction This chapter will present some of the findings from the survey that was undertaken by the researcher. Along with the conclusions provided by the initial survey conducted by the NGO, this chapter will include findings based on interviews by the researcher with the following: Table 4.1: INTERVIEWS CONDUCTED AT NONG K H A E M (JUNE-AUGUST 1993) Community Residents NGO Staff Community Leaders • 33 community residents • 11 residents who worked as daycare & health care workers • 1 project manager (and doctor) • 2 nurses • 1 project coordinator • 1 formal leader (appointed by BMA) • 1 informal leader (appointed by community) 44 interviewed 5 interviewed 2 interviewed Emphasis in this chapter will also be on the changes that have been implemented in the community with the assistance of the NGO and the involvement of the community. 4.2 Changes Implemented in Nong Khaem Community 4.2.2 The Community: Pre-NGO 68 Prior to the NGO coming into the Nong Khaem Community, a similar project was administered in 1988 in another slum community surrounding the garbage dump in Soi Onnut. The success of the Onnut project prompted the NGO to replicate the project in another area, hence the Nong Khaem project. Onnut is the largest of the city's three garbage treatment plants. As the treatment plants can only process a limited amount of garbage per day, "the rest is dumped in the open air, waiting for natural decomposition" (Bangkok Post. August 20, 1988). It was on these garbage dumps (known as garbage mountains) that the slum people around the dump site are earning their living as garbage sorters, looking for paper, plastic, bags, bottles or pieces of metal in exchange for money from scrap dealers. People of all ages (from 5 years old to the elderly) dig through the rubbish. The working conditions on the garbage mountains prove to be very dangerous to the health of the slum dwellers as, and according to van den Bosch, they get cuts and bruises that get infected and often inhale toxic materials. By working two years in the Onnut slum community, the NGO was able to improve the health conditions in the community considerably. It should be noted that although improving the health conditions of the community residents was a primary goal, the NGO according to van den Bosch perceived "health and the social environment as being so closely related that you can not work in one field leaving behind the other" (van den Bosch 1993). Although health conditions in Nong Khaem were found to be similar to those of Onnut (prior to NGO involvement), the living conditions were found to be worse. The results of a survey conducted by the NGO in the Nong Khaem community indicated that less than 30% of the children had been properly vaccinated; more than 40% of the children were malnourished; and a large 69 number of young mothers were unable to read or write. The experience gained by the NGO in working in Onnut helped in administering the Nong Khaem project successfully. 4.2.2 NGO Involvement: Community Development Initiatives The five NGO (Thai) staff members, excluding the doctor, were all university graduates. Through a questionnaire and informal discussions with the NGO staff, the researcher was able to gain some valuable information. The high turnover rate initially, in the first year, was attributed to the depressing conditions of slum life. Previous to working in Nong Khaem, only two of the members had any other experience working in slum communities. As suggested by Salmen (1992), training or experience in development work is essential for all the players involved. In this case, specific training such as adult education teaching and savings schemes projects were provided to the staff where required. After initial consultations with the BMA, the NGO team working with the Onnut project undertook a survey into the health of mothers and children in the Nong Khaem slum community to define the problems and plan a strategy for action. A total of 71 households (310 people) were interviewed. The results indicated that no GO or NGO was providing assistance to the community, and most of the residents were unaware of assistance programs. The reason for lack of assistance from other organizations was that the Nong Khaem community was considered to be located out of the way and difficult to reach. The survey findings indicated that given the opportunity, the community residents had no difficulty in expressing their needs and concerns. 70 It was discovered that 78% of families were living below the poverty line (earning an income of less than $150 per month). Compared to other slum communities in Bangkok, the length of residence was short, with 50% of the families having moved into Nong Khaem during the last 3 years (1987-1990). The NGO felt that since a number of the people arrived from one of the most impoverished areas of Thailand (Issan - in the northeast), they were unfamiliar with how to access municipal services (health care, education, etc). Many of the residents from Issan also returned home during the planting and harvesting season. Due to both the limited length of residence and the travel to and from Issan, many of these people were not integrated into the "old" community and made up a separate subgroup. Another problem identified in the community was that the low level of education amongst many of the women, and this was one reason attributed to why there was a large number of women becoming pregnant at a relatively young age (under 20 years). Very few of these women have a marriage certificate. The author in her research found it was difficult to establish who was legally married as 84% indicated they were married, and yet did not have a marriage certificate. The initial survey conducted by the NGO indicated only 15% were legally married, with 80% being "informally married". Van den Bosch identified this as one of the problems in the community as the men often felt that since they were not legally married it was acceptable to have many wives (referred to as "minor wives" in Thai society). In the NGO survey, 2 out of 3 children were found to be sick, mainly suffering from respiratory tract infections. In these cases, only 50% of the children were taken to a doctor. 71 Furthermore, only 17% of the children had a health record, indicating the lack of education for health care by the parents. Only 29% of the children were found to have been vaccinated with DPT. In the Nong Khaem project, health was used as the intervention/breakpoint (as refered to by Turner) into the urban poor community. Before the NGO set up the healthcare facility, the people had to travel a long distance to receive any healthcare and this meant that they lost a day of work and had to incur transportation expenses that they could barely afford. Thus, often they left their injuries untreated. The NGO (Foundation for Slum Childcare) recognized the immediate need for healthcare and thus arranged for external funding, which was eventually provided by the Canadian International Development Agency. In the project, the community participatory approach in health, which emphasized the bottom-up framework was adopted. Though it was an outside NGO that felt the pressing need for a health facility, the community was approached from the onset of the program. Recognizing the need for primary health care, the NGO received funding to jointly set up a healthcare and daycare facility. It is important to note that the NGO had specifically targeted women and children as the main agents of change, to encourage community development and improve the situation of the this urban poor community. Targeting women seemed to be a natural process in a health care 72 project, for, as mentioned by Osteria (1991) women have traditionally been the managers of local resources such as health services. In cases where the health system is geared to centrally funded physician care (like this one, where van den Bosch, a Belgian doctor, comes once a week), unless a major reorientation of the system is accomplished, formally established local committees will be sustained only so long as central project funds are available (Korten 1987). According to Korten (1987), there is a need for community health projects to call for the development of self-sustaining, self-financing local health committees to assume the leadership in local health matters. Now, it becomes important to see if this community can sustain itself for the long term. However, in an attempt to maintain the viability of the community, programs are already being established in addressing the needs of adult education, family responsibilities, and basic healthcare and nutrition. In the case of Nong Khaem, van den Bosch felt that the project could continue even if there was not a doctor on site, for the two nurses were there daily. The nurses were from outside of the community and their salaries were paid by the NGO. In summary, the NGO recognized that this segregated community existed because of their economic livelihood made from living off the garbage dump. There was some potential for community formation because of kinship ties among residents and the fact that some of the residents came from the same part of Thailand. However there was no formal community structure prior to NGO involvement. The larger task for the NGO, beyond improving health and living standards, lay in how the NGO could play a role in bringing about a formal sense of 73 community, as this is a prerequisite for any community to remain viable once the NGO leaves (this is a process defined as "capacity building" by Korten 1987 and Getubig 1991). 4.2.2a Health Clinic The health clinic served as an initial penetrating instrument to gain access into the community, and through some of its activities focusing both on health and social issues, a greater sense of community was encouraged and established. In Nong Khaem, the design of the program using health to intervene in the community was effective in dealing with urban poverty. The NGO was able to enter the community through appealing to one of the main community interests (Laquian 1969): health conditions. On site, six days a week the clinic is open to the community. If there is an injury or a need to visit a hospital after hours or on weekends, the residents will be reimbursed for costs if the situation was an emergency. The NGO attempts to encourage the residents to use the local facilities. Aside from the fact that the doctor, van den Bosch, is available on site for one day per week there is a qualified nurse available the other five days. The health care statistics of the community have been improved considerably since the establishment of the clinic. The most noticeable improvements, by 1992, were: malnutrition had decreased by 10% over 50% of the children in the community had been vaccinated almost all the pregnant women attended ante-natal care on a regular basis 80% of the women brought in their children for regular growth monitoring and check-up a decrease in number of drug-abusers was observed 74 a self-medication program had been set up through educating the community The success or progress of the project and the work being undertaken by the NGO staff was measured through bi-annual reports that were submitted to CIDA. These reports also served as a monitoring mechanism or checkpoint for the NGO, where they were able to evaluate the outcome and impact of different community initiatives to date. Improvements, such as those mentioned above (particularly the updated health records), helped to show the NGO that their work had a positive impact on the community, thus enabling them to move into other areas of community development work. Of the respondents 82% answered "yes" to using the health care facility. It is interesting to note that of the thirty female respondents, 97.6% used the health care facility while only 50% (7) of the male respondents did (see figure 4.1). One reason for this difference in use of the facility by gender may be that the NGO had specifically targeted women and children in its objectives for setting up the project. As a further note, of the eighteen respondents who were squatters, fifteen indicated using the health care facility. 4.2.2b Daycare Centre The idea of the daycare came about as the project manager became aware that many of the children in the community were not receiving proper care. Parents left their children at home during the work day or took to the garbage mountain to help pick garbage. As a result of this the children grew up in an unhealthy environment which was conducive to injuries and diseases. This prompted the NGO to submit a further proposal to CIDA for a 75 Figure 4.1: Use of Health Care Facility by Gender daycare facility, which was eventually opened in 1992. The daycare facility is open from 8:00 am to 5:00 pm six days a week for children under the age of five. The children are divided into three groups: one group with children under a year; one group one to two years and a third group for children between the ages of two to five. For the first group there was one nanny per three children; one nanny per five children between the ages of one to two years; and one nanny per seven children between the ages of two to five years. On average there was a total of fifty children in attendance per day. The cost to the parents is 20 Baht (approximately $1.00 Cdn) per day for one child and 30 Baht for two children. The parents drop off the children in the morning and pick them up at the end of the work day. At the daycare, the children are fed three main meals, two snack breaks and are bathed twice (with their hair washed every other day). Children accepted into the daycare program are required to visit the health clinic once a month and are required to maintain an up to date health and vaccination record. The parents are expected to spend 1 hour daily or half a day per week at the daycare centre, providing the care providers (referred to as "nannies" by the NGO staff) with an opportunity to educate the parents on proper child care strategies. In the 1993 proposed activity plan, parents were also expected to work on rotation under the supervision of the daycare staff. The care providers, being residents of the community, were trained as childcare workers. Every two months parent meetings were also organized with group discussions on topics such as child development and 77 proper parenting. In August 1993, the NGO staff were in the initial stages of designing a questionnaire to assess the impact of parent participation at the daycare facility. Figure 4.2: Use of Day Care by Monthly Household Income At the time of conducting the questionnaires, the researcher found that only 41% of the respondents indicated using the day care facility. Figure 4.2 shows that 77 .8% of the respondents with incomes levels of less than $1507month did not use the day care facility. The income group that most often utilized the facility were the respondents who earned between $151-$300/month. One explanation for the respondents, living below the poverty line in Thailand, and not using the facility may be due to the charge of $1 per day per child. In other words, they may not be able to or do not want to pay the fee. 78 4 .2.2c Playground According to the initial survey conducted by the NGO, one out of every 20 children under the age of five was left alone without any parental supervision. Hygiene conditions in the community were poor and children were in serious danger of being injured. As there was no facility or area available for small children to play around safely, the FSCC put in another proposal for a playground area to be located next to the daycare. The NGO objectives were: (1) to provide a safe and stimulating environment for small children in the slum during the daytime and (2) to instill in children a love and awareness for the environment from a very early age. This proposal was approved in 1992, and in December of that year the new playground was completed. Currently, the playground and the daycare facility are both being used to organize regular community activities and thus have become a centre for community development, according to van den Bosch. 4 .2 .2d Social Development Activities The health care workers who were hired for the project were mothers from within the Nong Khaem community. The workers were selected on the basis that they had been long term residents within the community; were both familiar and well received by other community residents; were older than 22 years of age; and had completed primary school education. Each of the health care workers underwent a training course in mother and child health and also received additional training from the Onnut health center. 79 There were many problems identified in the survey, and helped to focus the activities undertaken by the NGO to improve the health and livelihood of the Nong Khaem community residents. Some of the problems identified by the NGO and solutions that were implemented can be seen in the table 4.2. Table 4.2: Problems and Activities Initiated by NGO Community Problems Solutions by NGO (interventions) Results Achieved •Unhealthy community • Set up a health clinic •Improved health •Young children not cared for by working mothers • Set up daycare facility •Playground facility •Improved health and leisure for children & less stress for parents • Lack of formal education among adults and children • Adult classes offered in the evenings, utilizing the daycare as space • Savings schemes for children's future education •Impact yet unknown, as project was to start in 1994 • Family breakdown • Family outings •Parents spending time at daycare with children •Educating family through courses • Gradual recognition by fathers to take more active role in raising children • Lack of play space for children in community • Set up a playground next to daycare, so that children had a play area during the day • Safe and stimulating environment for children • Space sometimes used to organize community activities (centre for community development) • Environmental • Spoke with formal leader to take active role in working with BMA • Results yet to be seen The activities as of 1993 that were up and running were the following: (1) Mother & Child Health Program which offered pre and post natal care, family planning, child health clinic, 80 nutrition education programme, general health care; (2) Social Development Program - day care centre at Nong Khaem, family outings, adult education program. Family outings were planned four times a year with the purpose of making parents spend quality time with their children away from the stresses of their daily lives. Gatherings which involved the fathers were also organized to make them more aware and involved in the rearing of their children. It is interesting to note that in conversation with van den Bosch, she mentioned that it was difficult to define 'family' especially in the case of Nong Khaem, where many broken families existed and the responsibilities amongst the family members were not shared equally. Van den Bosch believes that much of community development work lies in working with the women through empowering them. In terms of the future goals of the NGO greater emphasis was to be placed on social development initiatives: occupational training; developing women's role in the community and child development programs. Planned activities for 1993 also included discussions with the community on such topics as on "drug use habits in Nong Khaem"; "Milk as a food-supplement for under-fives"; "understanding of the under-five clinic"; and an education campaign on AIDS was also being prepared. A social worker was also to be hired to work throughout the year on gathering data on the expectations of children in the community and the expectations of their parents; family situations; future perspectives and youth delinquency. Separate activities were also being planned for the youth of the community. 81 For the community daycare program, the NGO staff wanted to improve the family relationships of the children enrolled in the program and strengthen the family unit and improve child-rearing in the community. Hence, there were frequent home visits by the daycare staff in which they were trained in the counselling on family problems. As the daycare staff were trusted by the community, by being part of the community, the community residents felt more comfortable in voicing their concerns and needs. The NGO staff working in Nong Khaem are able to attend workshops and undertake training as required for their positions. In addition, the NGO staff were required to submit their own programs that they wanted to implement in order to meet the needs of community. The manager of the day care, for example, was involved in a number of different projects: a savings scheme, where she was responsible for obtaining money from the parents to invest in the future education of their children; education programs on teaching parents on child rearing practices; progress meetings with the parents of the children; and an attempt to set up a community organization. The manager felt that if the threat of eviction did not exist, a community organization could be established. Regular meetings (four times a year); a yearly team building seminar; and an annual training session on community participation allows the NGO staff to come together and share their ideas on the future direction of the project. Feedback from the community residents is appreciated and encouraged in designing the programs. 4.4 Post NGO: Community Viability? 82 The question of whether Nong Khaem will be able to sustain the activities that have been put into effect, is a difficult one to answer. As mentioned repeatedly in chapter three and this chapter, the Nong Khaem community does not have an effective community organization in which they can channel their concerns through and eventually arrive at some solutions using their local resources. The need for a community organization is immediate, especially for any community self-help initiatives to be pursued. The organization could provide a voice to address the community needs, allowing for the transfer of some responsibilities from the NGO to the community. Although an effective formal organization does not exist, it should be noted that in Nong Khaem an informal community structure does exist. This can be seen through the mutual aid that exists between the neighbours in providing childcare; sharing domestic chores; assisting in building shelter, etc. The majority of the respondents (91 %) indicated helping their neighbours in some fashion, as previously mentioned. According to Korten's three generations of NGO efforts, Nong Khaem project is between the 1st and 2nd generations. The NGO was concerned with community development initiatives after the initial establishment of the health care and day care facilities (this is an example of Korten's first stage, characterized by a NGO's relief efforts). However, the provision of health services was not enough to sustain a community. The second generation is characterized by the energies of the NGO being expended on developing the capacities of the people to better meet their own needs through self-reliant local action (Korten 1990). Korten refers to this stage as 83 community development strategies. The stress is on local self-reliance with the intent that benefits will be sustained in the long term. There is also an intent to empower the people, and van den Bosch refers to the importance of empowering particulary the women of the community. She believes that since in Nong Khaem most of the childrearing and financial responsibilities lay in the hand of the women, then the focus of community development should be on and for women primarily. The NGO needs to maintain a facilitative and flexible role in encouraging community organization and people's empowerment. Training (advocacy, facilitative, and mediation) should be provided to the NGO staff and community representatives (selected by the community) to speak on behalf of other residents. This in turn would help to place the community in a strategic position to deal with local government authorities (BMA and NHA in the case of Nong Khaem). Training should also be made available on how to work effectively within the different bureaucratic levels. On behalf of the BMA and NHA, they need to be responsive to the needs addressed by the Nong Khaem community. Services which need to be made available to the community residents are to obtain legal marriage certificates; access to public education; vocational training; and security of tenure. In terms of sustaining the community health workers, especially if the NGO leaves, more attention needs to be paid to securing new ways of financing health services and on how to 84 improve the use of available resources by achieving greater cost-effectiveness in health activities o (Walt 1990). As funding for the Nong Khaem project is still continuing, limited attention has been paid to securing future funding. However, van den Bosch is able to secure funding through her own personal contacts when needed. For example, in 1993 year she obtained funding for a washing machine for the day care. One of the project managers was appointed responsible for a fund-raising program. 4.5 Summary The Nong Khaem Mother and Child Project is a positive initiative taken on the part of an NGO to become actively involved in one of the poorest slum areas in Bangkok. The significant improvements made in increasing the health standards of the community, especially for the women and children, should be recognized. However, a project of this sort takes a sincere commitment and dedication on the part of the dwellers, the NGO and the local government in making a real impact in a slum community. Though a lot of work still remains in improving and sustaining the living conditions and activities of the Nong Khaem community, some noticeable improvements have been made. As development work is often perceived as not "truly" benefitting the intended group (ie - the slum dwellers in this case), this project can be used as a model for other organizations, both governmental and non-governmental, to pursue in other slum communities. 85 CHAPTER 5 CONCLUDING REMARKS AND RECOMMENDATIONS 5.1 Introduction This thesis set out to examine: 1) the role of a local non-governmental organization attempting to develop an urban poor Bangkok community and 2) the establishment of a primary health care unit and its use as a catalyst for further community development, in which women were the targets to initiate change. The researcher believes that the role of the NGO; the use of health as the entry point into a community lacking any organization; and the involvement of women have all led to the success of the Nong Khaem Mother & Child Health Project. The research findings indicated that the project was perceived to be successful in the eyes of all the players involved: the NGO, the BMA, funding agency (CIDA), and most importantly the residents of Nong Khaem. The success also lay in the fact that the Nong Khaem project proved that funding did not have to be on a large scale to actually have a positive impact in this urban pooiA community. 5.2 Project Beneficiaries Nong Khaem Community The most direct beneficiaries of the daycare project were the children under the age of five and their families, as 10% of the community population used the facility. However with the intensive home-visiting and community outreach program that was introduced in the project, 86 the whole community benefitted indirectly. Employment was created for the local residents as the health care facility employed community members as health workers, janitorial, and kitchen staff. In addition, the whole community received better health care located right on the site. Since many of the women were often very young when their first child was bom, they were being educated on birth control and AIDS preventative measures. More women were being ensured that their babies would have a better chance of survival through the regular check-ups. For the children, a decent and safe daycare centre was provided where they were fed and taken care of while their parents worked. The community health care workers were also trained in community development approaches and they played a vital role in persuading the dwellers to realize the necessity of health care. Nongovernmental Organization The main benefit to the NGO, was the satisfaction that the project had been a success in bringing up the health standards of the community and providing a safe environment for the children. People more readily came to the health clinic for an injury rather than postponing the visit and thus they had learnt to avoid possible infections. The NGO had also been extremely successful in educating the women about birth control and pre/post natal care. As outlined earlier in this paper, the objectives pursued by the NGO had been met at the time the research was conducted by the author. 87 CIDA (Canada Fund) For the funding agency, the Canada Fund, the Mother and Child Health Care Project is recognized as an extremely successful project. The results in terms of the amount of users of the health clinic and the daycare facility exemplify the true benefit to the community of such a project. CIDA is now able to use this project as an example of how an NGO can assist a community, through a "grassroots" approach, to better their living conditions. The funds that were provided to the NGO directly benefitted the community and the NGO as well. BMA One of the obvious benefits to the BMA was that the collection of reusable waste materials by the scavengers helped to reduce the volume of waste which has to be treated and ultimately disposed of. It enabled industry to save energy during manufacturing since production from recovered materials used much less energy than production from new materials (Yap 1992). Scavenging at the dump site was the final phase of the recovery process and helped to provide the residents of the Nong Khaem community with a livelihood. The BMA also benefitted through the role that the NGO took in the provision of basic health care needs, because this role was traditionally one which is undertaken or initiated by a local government authority. 5.3 Recommendation: Sustainable Development Initiatives for Nong Khaem The answer to the question that was introduced in chapter 1: "Will the community be able to sustain the activities that are being implemented with the help of the NGO once the NGO 88 leaves the project?" is crucial to the long term success of the Nong Khaem project. However, as mentioned in chapter four, this is not an easy question to answer, as the community currently lacks the social infrastructure to maintain or sustain the activities on its own. This is not to say that there is no hope for sustainable development to occur in Nong Khaem; just that there needs to be a lot of work done in order to achieve this ultimate goal of community development projects. There has not been enough time to gauge whether the community has become self-reliant or not. Basically, whatever approach is decided upon, sustainability and inclusivity should be the underlying principles to encourage "real" community development in Nong Khaem. Inclusivity, meaning the and participation of all the stakeholders involved. The first and one of the most important recommendations the author puts forth is the need for community empowerment. Empowerment should be the basic role of any development project that is undertaken. In order for the Nong Khaem community to feel empowered and to become less dependent on external agencies for assistance, the community must establish a recognized community organization structure. The NGO can play an initial facilitative role in aiding the community to democratically put this structure in place. Inherent in all development work is the need for a participatory framework, which is inclusive not exclusive in design. An optimal mix of grassroots interests and a partnership approach which is tailored to the characteristics and needs of the Nong Khaem community, is 89 the strategy that should be strived for in attempting to develop a participatory approach. For participation to be meaningful in Nong Khaem, the community must first have the freedom to choose its leader. As was the case in Nong Khaem, the role of the formal leader may have impeded community development to a large extent for he was appointed by the BMA. The fact that he was not recognized by the community as the leader meant that the community's channel to reach the local government was closed. The only access point that the community could use to reach the BMA was the NGO, which, however, only had contact with the government for specific objectives (land for the facilities, supply of vaccines, etc). The NGO, using a participatory approach, could play a role in helping the community to secure a recognized leader. Women should play an integral role in this organization, as many of them have already been involved in the process of identifying problems in the Nong Khaem community. By having the women working together in an organization, they would have the collective strength and power to articulate their needs and in turn act on the shared concerns and interests. The women working as health workers should continue working with the NGO staff so that eventually some of the tasks and responsibilities being performed by the NGO can be delegated to them. There is a need for the BMA to become involved in providing the women with technical, logistical and moral support to sustain the projects independently if the NGO is to transfer responsibility to the community. i 90 Through adopting a people-centred approach, where the government plays an enabling role, the Nong Khaem community will be in a better position to develop itself. This approach also requires that there is respect for one another; respect for one's family; ones's neighbours; one's community; one's environment; one's culture and ones's world (Shuman 1994). By having the NGO, Nong Khaem community and the BMA working together, they can collectively promote this people-centred development approach to assist in empowering the residents to take action. For example, the "coalition" can take advantage of local level resources. At the present time, the Nong Khaem community needs to feel some ownership over any community development initiatives that are put forth, especially if the initiatives are to be sustainable over the long term. Another recommendation is that there also needs to be an emphasis on community self-reliance in Nong Khaem. The capacity to respond to local concerns and priorities needs to be developed, within the context of regional, national and global sustainable goals. According to the B.C. Round Table discussions (1993), community self-reliance also goes jointly with responsible citizenship, which represents a commitment to the well-being of one's community, both locally and globally. The Nong Khaem community needs to develop both the human and financial resources to become socially sustainable. This social self-reliance will help the Nong Khaem residents gain a sense of belonging and take ownership over community issues. It is positive to know, as indicated by the author's questionnaires, that the majority of the respondents were interested in participating in community betterment: thus, the will is there, but the skills and knowledge are lacking. 91 Ultimately, there should be a development process in place which emphasizes integration, coordination, and participation in a collaborative planning and decision-making structure. In Nong Khaem there is a need for a system of mutual cooperation where the community residents and the BMA are able jointly to make recommendations to the national government. Through cooperation and the sharing of information, progress can be made to increase the collective capacities of the residents, where better use of available resources can be used to meet their needs. In such a situation, the NGO can take the role of a catalyst, mobilizer, facilitator, analyst, and advocate for the community. The NGO can play a critical role in providing human care, but the balance of responsibility for ensuring well-being will need to shift to community self-reliance. In other words, there will need to be a transfer of responsibility from the NGO to the community, in order for the community to become self-sufficient. There should be an emphasis on enhancing the capacities of the Nong Khaem community members to meet their own needs through determining their own options and designing their own initiatives. Hence, training in skills and knowledge is another essential area that needs to be addressed in the Nong Khaem community. In the search to promote cooperation and partnerships to achieve social sustainability, there is a critical need that the government, community and NGO work together to meet the identified community goals. By placing greater emphasis on responsible citizenship, mutual support and social self-reliance, the Nong Khaem community can establish control over its 92 destiny and hopefully place less dependence on government funding. The NGO can play a catalytic role between the BMA and the community. To ensure that all the players are involved, multi-stakeholder processes at the community level should be used to ensure that everyone is involved in addressing the issues. A social equity system should be established, which allows for the residents of Nong Khaem to be involved in the decision-making process; to have equal opportunity for education and training; to have access to social support services and adequate housing; and to have the opportunity to earn a decent livelihood. As has been described in this thesis a social equity system has not existed and many of the residents have no access to public services due to the insecurity of tenure. The BMA should critically re-evaluate this situation. The BMA should develop and promote a client-centred approach, emphasizing local community initiatives. Training courses in community development should be provided for government officials, who in turn should work in partnership with the Nong Khaem community, the community leaders and the NGO. There should also be a decentralization in the delivery of government services to the local communities. The BMA should firstly attempt to be accountable to the community and then secondly be accountable to the larger regional, national, and global interests. In order for this to happen a cooperative regional planning approach should be adopted. The local government can also play a key role in establishing an overall policy framework of sustainability, where 93 community initiatives are facilitated and enabled. Therefore, the Nong Khaem community and the NGO should push for a strong local government which allows for the people to shape their own process in a democratic manner. Essential to this, once again, is the need for participatory planning in the decision-making process. The recommendations mentioned thus far have been long term in nature. The author is aware although the changes recommended are necessary, the process will be slow, particularly when functioning within a political structure. Thus, in the short term, the author recommends the following: (1) a need to support, enhance and strengthen the existing informal structures (ie -sharing in childcare, domestic chores and house construction); (2) provision of appropriate technology, such as teaching oratory skills before reading and writing to empower the residents to express themselves in an confident manner; (3) the NGO increases it use of the participatory approach to identify community needs, because this will help to increase the role of the community to be pro-active in meeting own needs; (4) a need for shared ownership, where community development initiatives will emerge from a confident empowered community and; (5) a need to instill a sense of pride and dignity. The fifth recommendation is extremely important, as the social status of waste pickers in most third world countries is low, and there needs to be a recognition by their societies of their contributing role to the economy (Furedy 1992). In the case of Nong Khaem, the garbage pickers are making a contribution to Thai society, where they are recycling approximately 5 % of all garbage accumulated in Bangkok. Therefore they should be recognized by the government 94 and other residents of Bangkok. For example, in the case of Indonesia, the Thai government could legitimize this informal waste work by acknowledging scavenging as an alternative approach to conventional waste management. Once scavenging is recognized as valuable work, the physical working conditions could also be improved upon. 5.5 Summary As the underlying goal of any development project should be sustainability and viability over the long term, the Nong Khaem Mother and Child Health Project needs a critical re-evaluation of the community development process to date. The project has been successful in meeting the objectives that had been put forth by the NGO initially, but now is the time for greater input from the community. 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United Nations Volunteers, (September 27-28, 1990), Informal Discussion Note for "UNV Special Consultation on Volunteer Participation in Working with the Urban Poor", Geneva. Walt, G., (1990) Community Health Workers in National Programmes: Just Another Pair of Hands?. Philadelphia: Open University Press. "Where home is a rubbish dump", (1988, June 26), Bangkok Post. "Women in the Development Process", (1991), Thai Development Newsletter. Bangkok: No. 19. Wong, M.L., (1991), Women in Health and Community Development: A Case Study of the Berawans in Sarawak. Singapore: Institute of Southeast Asian Studies. Yap, K.S., (1992), Low-income housing in Bangkok: A Review of some Housing Sub-Markets. Bangkok: Asian Institute of Technology. Yap, K.S., (year unknown) "The Urban Poor as Agents of Development: Community Action Planning in Urban Low-Income Settlements in Sri Lanka", Submitted to Habitat. Yeung, Y .M . and McGee, T.G. , (1986), Community Participation in Delivering Urban Services in Asia. Ottawa: IDRC-238e. Yin, R.K. (1989), Case Study Research: Design and Methods. California: Sage Publications. 101 Yoddumnern, A., Richter, K., Soonthorndhada, A., Sethaput, C , Pramualratana,A. (1992), Changing roles and statuses of women in Thailand: a documentary assessment. Bangkok: Institute for Population and Social Research, Mahidol University at Salaya. 102 APPENDIX A N O N G K H A E M QUESTIONNAIRE: COMMUNITY RESIDENTS Date of Interview: I. PERSONAL INFORMATION 1. Name of Respondent: 2. Sex: Female Male 3. Age: 4. Marital Status: Single Married Separated Widowed 5. Number of children: Age(s) of children: 6a) How many people do you live with? b) Relationship to you? H . SOCIO-ECONOMIC INFORMATION I. Place of Birth: 2. Length of stay in Nong Khaem: 3. Length of stay in Bangkok: 103 4. Previous places of residence(s) in Bangkok Place of Residence Period 5. Type of land titles: Owner Lessee Renter Squatter 6a) How long do you plan on staying in Nong Khaem? b) Where will you go next? 7a) Approximate household head's monthly income? b) Approximate monthly household income? 8a) Where do you work? If not single, where does your spouse work? b) How many days per week do you work? c) How many hours per day do you work? 9. Do you send money to anyone? Yes No If yes, how much do you send and to whom? 104 III. COMMUNITY INVOLVEMENT 1. What is your role in the community? Parent Neighbour Leader Community Member No role 2. Do you feel that you live in a close-knit community? Yes No 3. Do you know your neighbours well? Yes No 4. How often do you meet with your neighbours socially? times per week times per month 5. What cultural events/festivities do you celebrate with your community residents? 6. Do you help with your neighbours in the community? Yes No If yes, what do you help with? house construction household chores childcare other (please specify _ 7. What do you do in your leisure time? visit family/friends go to cinema travel other (please specify) _ 105 8. Is there a people's organization in your community? Yes No If yes, who is the leader? 9. What problems do you face in the community? 10. What other facilities would you like to see in your community? IV. D A Y C A R E / H E A L T H C A R E FACILITIES la) Do you use the daycare facility? Yes No If yes, how often per week? b) Do you use the health care facility? Yes No If yes, how many times per week per month per year 2. Were you consulted by the BMA and the NGO in deciding if you wanted a daycare/health care facility? By the BMA: Yes No By the NGO: Yes No 3. How many meetings have you had with the: BMA: times NGO: times 106 4. Would you have preferred something else to a daycare/healthcare facility? Yes No If yes, what else would you have liked?__ 5. Do you want to play a role in the future development of your community? Yes No Why yes/no? T H A N K Y O U FOR YOUR COOPERATION AND T I M E IN COMPLETING THIS QUESTIONNAIRE. 107 APPENDIX B QUESTIONNAIRE - RESPONSE K E Y # = COMMUNITY RESIDENTS (#) = DAYCARE/HEALTHCARE WORKERS (ALSO COMMUNITY RESIDENTS) I. PERSONAL INFORMATION: 1. Name of Respondent 2/3. Sex & Age of Respondents A G E (yrs) F E M A L E M A L E 0-20 3(1) 21-25 4(4) 3 26-30 6(2) 3 31-35 2(1) 3 36-40 1(2) 3 41-45 (1) 1 46-50 1 51-60 3 > 60 T O T A L (44) 19 (11) 14 4. Marital Status Single 1 (1) Married 30 (7) Separated (1) Widowed 2 (1) 108 5. Number of Children none 3 one 10 (4) two 9(4) three 5(1) four 4(1) five 1 six 1 > six 6. How many people do you live with? alone 2 two 1(1) three 9(3) four 6(3) five 8(1) six 3(1) seven 2(1) eight 2(1) > eight 1 H . SOCIO-ECONOMIC INFORMATION: I. Place of Birth Bangkok 9(6) Central Thailand 13 (3) Northern Thailand 2 Northeast 8(1) Southern Thailand 2) 109 2. Length of stay in Nong Khaem < one 6 year 1-5 (yrs) 12(2) 6-10 21 (3) 11-15 5(1) 16-20 (1) > 20 2(4) years 3. Length of stay in Bangkok > one year 3 1-5 12 (1) 6-10 1 11-15 1(1) 16-20 6(1) 21-30 4 > 30 4(1) Since birth 6(4) 4. 5. Type of Land Title Owner 3(3) Lessee (1) Renter 13(5) Squatter 16(2) 110 6a. How long do you plan on staying in Nong Khaem? until evicted 6(5) until not allowed to rent 4 for a long time 10 (2) until retired 1 until no garbage 1 forever (until death) 6(3) uncertain 4(1) b. Where will you go next? no plans to go anywhere do not know to the province(s) no where, because we own the land to wherever the BMA moves the garbage another area in BMA 15(2) 8(2) 4(2) 3(2) 2(2) Tal Approximated household head's monthly income 0-1,000 Baht (B)* 1 1,000-2,000 B 5(1) 2,000-3,000 6(2) 3,000-4,000 10 (4) 4,000-5,000 4(2) 5,000-6,000 2(1) 6,000-10,000 3 11,000-15,000 > 15,000 (* $1 CDN = 20 Baht) 111 b. Approximate monthly household income 0-1,000 Baht 1,000-2,000 B 1 2,000-3,000 4(1) 3,000-4,000 6(1) 4,000-5,000 3 5,000-6,000 8(2) 6,000-10,000 10 (5) 11,000-15,000 (2) > 15,000 8a. Where do you work? Scavenge garbage 17 unload garbage 2 drive BMA truck 2 factory 1 sells things 1 tailor 1 daycare/healthcare worker .(11) at the home 6 does not work 2 money lender in community 1 112 If not single, where does your spouse work? Scavenge garbage 11 housewife 2 prison guard 1 factory 2(1) sells things 3(1) metal worker 2 BMA staff 2(4) drives BMA truck 2(2) motorcycle transportation (soi boy) 3 d ) b. How many days per week do you work? one - three days three - five 1 five 4(11) six 6 daily 15 c. How many hours per day do you work? 1-3 hours 3-5 1 5-7 1 7-10 12 (11) 11-14 2 15-20 6 whenever need to 2 113 9. Do you send money to anyone Yes 9(6) No 24(5) If yes, how much and to whom Parents 4(5) Children 3 Wife 1 Relatives 1 Bank deposits (1) m. COMMUNITY INVOLVEMENT: 1. What is your role in the community? Parent 20 (10) Neighbour 26 (8) Leader (1) Community Member 29 (9) No role 1 2. Do you feel that you live in a close-knit community? Yes 30 (11) No 3 3. Do you know your neighbours well? Yes 23 (7) No 10(4) 114 4. How often do you meet with your neighbours socially? daily 11(6) 1-3 times/week 6 3-6 times/week 1 greet casually on the street 7(5) not often/never 5 5. What cultural events/festivities do you celebrate with your community residents? Funerals 5 Make merit together 16(2) Weddings 5(2) New Year's 18 (10) Songkran (Thai New Year's) 14(4) Queen's day 1 Mother's day 2(2) Entering monkhood 3 go the province to celebrate 4 none 3 Buddhist lent 3(3) 6. Do you help your neighbours in the community? Yes 29 (11) No 4 115 If yes, what do you help with? House construction 16 (3) Household chores 3 d ) childcare 7(8) festivities 13(4) build roads 2 prepare land 2 water drainage 1 counselling neighbours 1 clean community 1 7. What do you do in your leisure time? visit family/friends 11 (6) cinema 1 (2) travel (1) watch t.v. 5(3) household/domestic chores 11 (2) childcare 3(1) shopping 2 sleep 10 (1) construction 1 play cards 2 drink alcohol 1 8. Is there a people's organization in your community? Yes 1 (2) No 30 (9) 116 9. What problems do you face in the community? Risk of fires 1 Garbage, dirtiness 2(2) Water supply 4(2) Electricity 1 (2) Lack of Money 1(1) Flooding 4(3) no fixed address (1) mosquitos 1 selling garbage too cheap 1 road access to site 2 gambling/drugs 4(2) family problems (1) crime 1 finding adequate shelter (3) low education levels (1) do not face any 15 (3) 117 10. What other facilities would you like to see in your community? Fire extinguisher 2 improve roads to prevent flooding 8(7) Drainage 1 Water supply 4(1) Electricity 4(1) public telephone 2(1) library/community centre (2) cleaner community 1 do not want anything 2(2) do not know 9(1) IV. D A Y C A R E / H E A L T H C A R E FACILITIES: la. Do you use the daycare facility? Yes 11 (9) No 22 (2) b. Do you use the healthcare facility? Yes 22 (10) No 11 118 How often per year? once/year 1 twice 2 3-4 times 5(3) 4-11 times 3 monthly 10 (6) as needed 7(2) 2. Were you consulted by the BMA and NGO in deciding if you wanted a daycare/health care facility? By the BMA? Yes 6(1) No 27 (11) By the NGO? Yes 19 (10) No 14 (1) 3. How many meetings have you had with the: BMA: None 19 (7) only once 3(2) 1/month 1 4/year 2 NGO: None 18 (1) only once 1(1) 1-4/year 7(1) monthly (6) 119 4. Would you have preferred something else to a daycare/healthcare facility? Yes 6(5) No 25(5) If yes, what else would you have liked? Better drainage 1 public telephone 2 school on site 1 cooperative store (3) job training centre (2) public library (1) medical benefits (1) place - cure drug addicts (1) 5. Do you want to play a role in the future development of your community? Yes 30 (8) No 3(1) want to develop community 15(5) want better living environment/ more comfortable 15(5) safer streets for children 1 want people to have better heart 1(1) because community member 2 need everything 1 do not know why, but want to help 1 (1) If no, why? because does not know 1 how to help community 121 

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