UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

Epistemological relevances in community-based health care programmes in the republic of Kenya Willms, Dennis George 1984

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-UBC_1984_A1 W54.pdf [ 21.18MB ]
Metadata
JSON: 831-1.0096597.json
JSON-LD: 831-1.0096597-ld.json
RDF/XML (Pretty): 831-1.0096597-rdf.xml
RDF/JSON: 831-1.0096597-rdf.json
Turtle: 831-1.0096597-turtle.txt
N-Triples: 831-1.0096597-rdf-ntriples.txt
Original Record: 831-1.0096597-source.json
Full Text
831-1.0096597-fulltext.txt
Citation
831-1.0096597.ris

Full Text

EPISTEMOLOGICAL RELEVANCES IN COMMUNITY-BASED HEALTH CARE PROGRAMMES IN THE REPUBLIC OF KENYA By DENNIS GEORGE WILLMS B.A. (Honours), University of Waterloo, 1972 M.A., McMaster University, 1975 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEC-REE OF DOCTOR OF PHILOSOPHY i n THE FACULTY OF GRADUATE STUDIES Department of Anthropology and Sociology We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA A p r i l 1984 (c) Dennis George Willms, 1984 In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f the requirements f o r an advanced degree a t the U n i v e r s i t y o f B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and study. I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e copying o f t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the head o f my department o r by h i s o r her r e p r e s e n t a t i v e s . I t i s understood t h a t copying or p u b l i c a t i o n of t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be allowed without my w r i t t e n p e r m i s s i o n . Department o f A n t h r o p o l o g y and S o c i o l o g y The U n i v e r s i t y of B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date A p r i l 2 i t 1 9 8 A DE-6 (3/81) ABSTRACT T h i s d i s s e r t a t i o n examines the problem of •community-based h e a l t h care* (CBHC) as i t i s i n t e r p r e t e d i n t h r e e separate h e a l t h c a r e domains. In r e l a t i o n t o the i d e a l i s t i c model f o r CBHC (or 'primary h e a l t h care*) propounded by WHO and UNICEF, h e a l t h care o r g a n i z a t i o n s i n the Republic of Kenya have c o n s t r u c t e d CBHC programmes t h a t r e f l e c t the c o n t i n g e n c i e s and r e l e v a n c e s of t h e i r s i t u a t i o n . T h i s t h e s i s demonstrates how these e p i s t e m o l o g i c a l d i f f e r e n c e s towards CBHC are p r e d i c a t e d on o r g a n i z a t i o n a l c o n s i d e r a t i o n s i n government, non-government, and independent programmes. In the Kenyan h e a l t h care context, the event of CBHC has accentuated the d i f f e r e n c e s between: an u r b a n / r u r a l a l l o c a t i o n of h e a l t h c a r e r e s o u r c e s , s a l a r i e d / v o l u n t e e r h e a l t h care workers, m o d e r n / t r a d i t i o n a l i n f l u e n c e s , and complex/subsistence economic standards. The M i n i s t r y of Hea l t h (Case 1) has embarked on a n a t i o n a l CBHC programme because of p o l i t i c a l (harambee: an emphasis on s e l f - h e l p development) and economic ( a i d - r e l a t e d monies) c o n s t r a i n t s . Yet b u r e a u c r a t i c i n f l e x i b i l i t y and entrenchment i n the c u l t u r e of biomedicine cause i t to be i n d i r e c t l y opposed to the CBHC s t r a t e g y ; consequently, i t i s proving t o be an - i i -i n e f f e c t i v e instrument i n the development of CBHC programmes. Community l e a d e r s i n the S a r a d i d i R u r a l Health Development P r o j e c t (Case 2) have assumed a c o m p e t i t i v e posture i n response to government n e g l e c t i n the development o f the h e a l t h care i n f r a s t r u c t u r e i n t h e i r a r ea. Through the c o n s t r u c t i o n of a comprehensive development programme (CBHC and income-generating p r o j e c t s ) , they have d e l i b e r a t e l y separated themselves from e x t e r n a l i n t e r f e r e n c e and c o n t r o l , f u r t h e r m o r e , the r e v i t a l i z a t i o n of t r a d i t i o n a l Luo s o c i a l i n s t i t u t i o n s has strengthened t h i s e f f o r t . i n the Nangina Community. H e a l t h Programme (Case 3 ) , e x p a t r i a t e m i s s i o n - h o s p i t a l communities have cooperated with e x t e r n a l h e a l t h c a r e agencies, and most i m p o r t a n t l y , with clan-based groups who support the a c t i v i t i e s of t h e i r r e p r e s e n t a t i v e Community H e a l t h Workers (CHHs) .... The impetus f o r t h i s o r g a n i z a t i o n o f CBHC i s a t t r i b u t e d t o the emergence of C h r i s t i a n Community Groups (CCGs). The philosophy of h e a l t h care t h a t has emerged i s p r e d i c a t e d on the s p i r i t u a l • r e v i v a l * i n the a r e a , and i s expressed i n the r e v i t a l i z a t i o n o f t r a d i t i o n a l s o c i a l i n s t i t u t i o n s of c a r e . R e l a t i v e t o these s e p a r a t e s o c i a l o r g a n i z a t i o n s , the ep i s t e m o l o g i e s of CBHC t h a t emerge are r e f r a c t e d i n the p o s i t i o n of the Community Health Workers (CHHs). •Horthwhileness,' i n one word, encompasses the r e l a t i v e t r u t h s and concomitant h e a l t h care goals t h a t CHHs i n each of these CBHC s i t u a t i o n s a p p r e c i a t e . , These images of worthwhileness are v a r i e d , and r e f l e c t the r e a l i t i e s of the o r g a n i z a t i o n i n which they work; t h e i r phenomenological c h a r a c t e r i s symbolized i n p r o f e s s i o n a l [ M i n i s t r y Of H e a l t h ) , p r o g r e s s i v e (Saradidi) , and s p i r i t u a l [Sangina)] metaphors. The t o t a l s i t u a t i o n of CBHC i n the Republic of Kenya encompasses these s e p a r a t e , yet impinging o r g a n i z a t i o n s of •community-based h e a l t h c a r e . ' The d i f f i c u l t i e s that emerge betseen programmes i s e x p l a i n e d i n terms of these d i f f e r i n g e p i s t e m o l o g i e s ; these i n t u r n are i n t e r p r e t e d i n r e l a t i o n t o o r g a n i z a t i o n a l r e l e v a n c e s . - i v -TABLE OF CONTENTS ^SSXfi&OjT • . • • • • • • • * • - * • . • . • • XX-. LXST OF FIGURES * • • • • • • # • * • V ABBBEvTATIOHS ....... . . . . .. - . . . JPR£F&C£ • • * * • • . • • . • XX Chapter page I . INTRODUCTION . . . . .. ....... . . . . . . ........ . 1 The A n t h r o p o l o g i c a l Problem . . . . . . . . . . 1 The Language, Symbolism, and C u l t u r e of "Community-Based Health Care" . . . . . . 5 D e f i n i t i o n s and Proposals of WHO and UNI CEP . . . . ...... . . • • „• • . . , • » . 5 Problems I d e n t i f i e d i n the Implementation and Management of CBHC Programmes ....... 10 The Impinging S i t u a t i o n of the Community H e a l t h Workers (CHHs) . . . . . . . . . 11 I d e o l o g i c a l Background t o the I n t e r v e n t i o n of CBHC as a Health Care Development S t r a t e g y . . . . . . . . . . . . . . ........ 18 The "Harambee" Movement . . . . . . . . . . . 19 The Current P o l i t i c a l , S o c i a l , and Economic S i t u a t i o n i n The Republic of Kenya; Problems of "Development" ....,23 Harambee, Development, and Community-Based Health Care; S i m i l a r Problems of Support, Mediation, and Involvement . . . . . . . „..,„. . .... . . . 27 T h e o r e t i c a l C o n s i d e r a t i o n s ; Ihe Ethnographic S i t u a t i o n of CBHC Programmes i n Kenya ..,.,30. Complex, S u b s i s t e n c e , and Peasant S o c i a l O r g a n i z a t i o n s : The S i t u a t i o n of Impinging S o c i a l - C u l t u r a l R e a l i t i e s x u G J3 H Q • • . • » . • * • * . 3 5 R e l a t i o n s h i p s , S t r u c t u r e s , and Events i n Ethn o g r a p h i c E x p l a n a t i o n . . . . . ...,38 Person, I n d i v i d u a l , and I n d i v i d u a l i t y . . . . 4 2 - 'v -I I . THE PROBLEM OF MCOMMUMITY-BASED HEALTH CARE": THE CASE OF THE MIHISTRY OF HEALTH, REPUBLIC OF KEMYA . . . . . . . . . . . .... . . 53 I n t r o d u c t i o n . . . . . . . . . .. . . . . . . . . 53 The C o n c e p t u a l i z a t i o n of an Informal "Community-Based Health Care" P o l i c y . . . 5 9 The B u r e a u c r a t i c Context . . .............. ,. . . 59 A C h r o n i c l e of Planning and P o l i c y Events i n the Process of C o n c e p t u a l i z i n g Community-Based Health Care . . . 66 Pr o p o s a l f o r the Improvement of R u r a l H e a l t h S e r v i c e s and the Development of R u r a l H e a l t h T r a i n i n g Centres i n Kenya . . . . . 66 The Development Plan: 1979-1983 . . . . . 68 I n t e g r a t e d a u r a l Health S e r v i c e s Programme . . . . . . . . . . . . . 70 I n t e r n a t i o n a l Conference on Primary H e a l t h c a r e . . . . . . . . . . . . 72 An I n t e g r a t e d S u r a l Health and Family P l a n n i n g Programme (IRH/FP) . . .,..73-A Review of the Conceptual Process i n the Form u l a t i o n of "Community-Based Health Care" . . - . 7 4 The S o c i a l O r g a n i z a t i o n of an "Experimental" Community-Based Health Care Programme . . 79 F o r c i n g the Issue of Community-Based He a l t h Care: The B u r e a u c r a t i c C o n s t r a i n t s . . . . *.....„. . . . . . . 79 On " I n t e g r a t i o n " . . . . . . . . . . ;.. . . 8 2 On "Community P a r t i c i p a t i o n " . . . . . . . 83 The "Family Health F i e l d E ducator" (FHFE) Programme 84. Proposal f o r the O r g a n i z a t i o n of a N a t i o n a l "Community-Based H e a l t h Care" Programme . . . . . . . . . . . . . 86 The S h i f t i n g Paradigm . . . . . . . . . . 8 7 Proposed C e n t r a l and D i s t r i c t L e v e l O r g a n i z a t i o n . . . . . . . . . . . . 89 Proposed O r g a n i z a t i o n a t the "Community" L e v e l . . . . . . . . . 92 The Community Hea l t h Workers (CHWs) . . . 95 D i s c u s s i o n o f the M i n i s t r y of Hea l t h ' s O r g a n i z a t i o n a l Scheme f o r Community-Based Health Care (CBHC) ..,,,96. The Management of a N a t i o n a l Community-Based Health Care Programme . . . . . . . . . . 100 Management Problems i n the P i l o t P r o j e c t D i s c u s s i o n o f the M i n i s t r y of Health's Management Problems i n Community-Based Health Care (CBHC) . . . . . . 104 - vi -D i s c u s s i o n of the M i n i s t r y of Health's S o c i a l C o n s t r u c t i o n of "Community-Based Health Care" . ............. . . .. . 106 A Review o f the E p i s t e m o l o g i c a l Dilemma . . 106 A C r i t i c a l Problem i n the Implementation of a Government "Community-based Hea l t h Care" Programme . .... . . . . . 10* I I I . , THE SABADIDI BUBAL HEALTH DEVELOPMENT PROJECT: THE CASE OF AH INDEPENDENTLY CONSTRUCTED CBHC PROGRAMME . . . . . . . . . . . . . . 122 I n t r o d u c t i o n . . . . ,. . . . . . . . . . . . . . . 122 Settxng . ..... ... . . ... ... ... 123 Climate and Environment . . . . . . . . . . . 128 P o p u l a t i o n and Health Needs . . . . . . .... . 132 C o n c e p t u a l i z a t i o n and I n i t i a t i o n of the S a r a d i d i R u r a l Health Development P r o j e c t (SRHDP) . . . . . . ... . . . . 133 A C h r o n i c l e of P r o j e c t Events . . . . . . . 134 A D i s c u s s i o n o f the I n i t i a t i o n of the S a r a d i d i R u r a l Health Development P r o j e c t (SRHDP) . . . . . . . . . .. . 142 "Community" over "Church" . . . . . . . 142 Two Types of Leaders . . . . . . . . . . 143 The P r o j e c t i n R e l a t i o n t o Hjarambee P r o j e c t s . . . . . . . . . . . . . 144 The Need f o r C l i n i c a l S e r v i c e s . . . . . 145 The S o c i a l O r g a n i z a t i o n of the S a r a d i d i R u r a l H e a l t h Development P r o j e c t (SRHDP) . . . . . . . . . . . . . . ...... 146 The E x e c u t i v e Committee (EC) . . . . . . . 149 D e s c r i p t i o n and F u n c t i o n of the E x e c u t i v e Committee (EC) . . . .... 149 The Experience of E x e c u t i v e Committee Members i n the S a r a d i d i R u r a l H e a l t h Development P r o j e c t . . . . 152 The I n i t i a t i o n of Income Generating P r o j e c t s . . . . . . . . . . . . . 155 E p i s t e m o l o g i c a l Issues . . . . . . . . . 157 The V i l l a g e Health Committees (VHCs) . . . 160 D e s c r i p t i o n and F u n c t i o n of the V i l l a g e Health Committee . . . . . 160 The R e l a t i o n s h i p to the E x e c u t i v e Committee (EC) . . . . ... . . . . . 163 The R e l a t i o n s h i p t o the V i l l a g e H e l p e r s Towards H e a l t h (VHsTH) . . 164 Problems of Development: H e a l t h Care Knowledge or Income-Generating P r o j e c t s . . . . . . . . . . . ...... 165 The P r o j e c t D i r e c t o r (PD) . . . . . . . . . 166 The F u n c t i o n of the P r o j e c t D i r e c t o r i n the S a r a d i d i R u r a l H e a l t h Development P r o j e c t . . . . . ....... 166 - v i i -The Experience of the P r o j e c t D i r e c t o r Within and Without the S a r a d i d i Community . . . . .. . • . . .. 169 The P o s i t i o n of Leaders i n the Development of Community-Based H e a l t h Care: The S i t u a t i o n of S a r a d i d i . . .. . . . . . . . . .. . 172 The V i l l a g e Helpers Towards He a l t h £ VHsTH) . . . . . . . ................. 175 Naming the Community Health Worker . . . 175 S e l e c t i o n and T r a i n i n g of V i l l a g e H e l p e r s Towards Health (VHsTHJ . . 176; A c t i v i t i e s of the V i l l a g e Helper Towards Health i n the V i l l a g e and a t the C l i n i c . . . . . . . . 177 T r a d i t i o n a l or P r o f e s s i o n a l O r i e n t a t i o n s : The Dilemma of the V i l l a g e H e l p e r s Towards H e a l t h . . . . . . . ,. . . . . . ... 180 A D i s c u s s i o n of the o r g a n i z a t i o n of the S a r a d i d i R u r a l Health Development P r o j e c t (SRHDP) . . . . . . . . . . . . 184 D i s c u s s i o n and I n t e r p r e t a t i o n : The C o n s t r u c t i o n of an Independent Community-Based Health Care Programme . 187= I d e n t i f i c a t i o n of Needs i n the Community . 188 The C r e a t i o n of Community: The O r g a n i z a t i o n a l Response . . . . . . . 189 E p i s t e m o l o g i c a l C o n s i d e r a t i o n s . . . . . . . . . 191 IV. NANGINA COMMUNITY HEALTH PROGRAMME: THE CASE OF CBHC IN THE ENVIRONS OF A MISSION HOSPITAL . . . . . . . . . 203 I n t r o d u c t i o n . . . . . ... . . . . . . 203 3 61 ^> i xi (j • • . • , » • _ • • . » . • 207. Climate and Environment . . . . . . . . . . 207 Po p u l a t i o n and Health Needs . . . . . . . . 209 The Conceptual Process i n the C o n s t r u c t i o n of Nangina's Community-Based He a l t h Care (CBHC) Programme . . . . . . . ....... 212 Nangina H o s p i t a l ...... • • • . • ....„-., 213 Towards the Formation of " P u b l i c H e a l t h Committees" i n the Community . . . . . . . . . . . . 214 The N u t r i t i o n Aide F i e l d Worker (NAFW): A worker i n the Community ... . . . . . . . . . . . 216 C h r i s t i a n Community Groups (CCGs) as a V e h i c l e f o r Community-Based H e a l t h c a r e (CBHC) . . . . . . . . 218 The C o n s t r u c t i o n of the CBHC A l t e r n a t i v e : A Summary of Events at Nangina H o s p i t a l . . . . 219 v-Wi -Nangina M i s s i o n . . . . . . . . . . . . . . 221; C h r i s t i a n Community Groups (CCGs) . . . 222 Community Health Workers (CHWs) . . . . 223 Father N and the Core Group . . . . ........ 225 " L i f e i n the S p i r i t " Seminars . . . .,. . 226 The S p i r i t u a l and Conceptual Tr a n s f o r m a t i o n of Nangina M i s s i o n and P a r i s h : A Summary of the C o n s t r u c t i o n o f C h r i s t i a n Community Groups [CCGs) . ,.. . . . 227 The S o c i a l O r g a n i z a t i o n of Nangina's Community-Based Health Care [CBHC) Programme . . . . . . . * . . . . . . . 230 Nangina H o s p i t a l and the Community He a l t h Workers (CHWs) . . . . . . . . . . . 233 S i s t e r Dr. L (Medical O f f i c e r of Health) . . . . . . . . . . . . . 233 A (Kenya community Nurse / Family Planning) and B ( P u b l i c H e a l t h Aide) . . . . . . . . . ........ . . 237 The P o s i t i o n and Experience of Community Health Worker T r a i n e r s / S u p e r v i s o r s at Nangina H o s p i t a l : A Summary Statement . . 239 Nangina M i s s i o n and the Community Health Ho.xrfc6ir*5 * • • • . • , . • • • . • . . » , • • . ^ Father N and the Community H e a l t h Workers (CHWs) . ....... . . . . . . 244. The P a r i s h C o u n c i l and the Community H e a l t h Worker . . . . . . ... . . . 246 The R e l a t i o n s h i p of Nangina M i s s i o n (the P r i e s t and Members of the P a r i s h Council) t o the Community H e a l t h Workers; A Summary Statement . . . . . . . . . . . . 247 C h r i s t i a n Community Groups (CCGs) and t h e i r Community Health Workers (CHWs) • . . • • . . . . . . . . . . . . . . . 249 Lea d e r s h i p i n the C h r i s t i a n Community Groups (CCGs) . . . . . . . . . . 252 S o c i a l Features of the C h r i s t i a n Community Groups (CCGs) . . . . . . 254. A c t i v i t i e s of the C h r i s t i a n Community Groups (CCGs) . . . . . . . . . . 258 E p i s t e m o l o g i c a l C o n s i d e r a t i o n s i n the S o c i a l O r g a n i z a t i o n of the C h r i s t i a n Community Groups (CCGs): A Summary Statement . ,. ,. 259 Community He a l t h Workers (CHWs) . . . . . . 262 S e l e c t i o n . . . . . . . . . . . . . . . . . 262 T r a i n i n g . . . . . . . . . . . . . . . . . . 263 A c t i v i t i e s . . . . . . . . . . . . . . . 265 - i'X- -Problems Encountered by the Community H e a l t h Worker ... . . . . .. . . . 271 The Community Health worker's Experience of Support . . . . ....... 273 An E p i s t e m o l o g i c a l Predicament: A Summary Statement of the Community Health Worker's S o c i a l S i t u a t i o n . . . . .. . • • . • • • 275 D i s c u s s i o n and I n t e r p r e t a t i o n : The S o c i a l C o n s t r u c t i o n of the Nangina Community-Based H e a l t h Care Programme . .. . . . . 279 I d e n t i f i c a t i o n of Needs: . . . . . . . . . 282 Symbolic Events and E p i s t e m o l o g i c a l Relevances . . . . . . . . . . . . .,. 284 The T o t a l S i t u a t i o n . . . . . . . . . . . . . . 288 ¥..,. CONCLUSION . . . . . . . 301 I n t r o d u c t i o n . . . . . . . . . . . . . . . . . 301 The "Event" of "Community-Based H e a l t h Care" [CBHC) . . . . . . . . . . . . . . . . . 303 S t r u c t u r a l C o n s i d e r a t i o n s . . . . . . . . . . 304 E s p i s t e m o l o g i c a l Relevances and Community Health Worker S i t u a t i o n s . . . . . .... . 309 Co n c l u s i o n . . . . . . . . . . . . . . . . . . . 315 BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . 319 - x LIST OF FIGURES T i t l e Pag_e (s) F i g u r e 1. Kenya 2 F i g u r e 2. Maternal C h i l d Health (MCH) C l i n i c 14-15 F i g u r e 3., S i t e of M i n i s t r y of Health -- Headquarters i n N a i r o b i 58 F i g u r e 4. Kenya Community Nurse (KCN) 64 F i g u r e 5. A d m i n i s t r a t i v e O r g a n i z a t i o n Proposed by the M i n i s t r y of Health i n Kenya 81 F i g u r e 6. S i t e of S a r a d i d i R u r a l Health Development P r o j e c t , S i a y a D i s t r i c t , Nyanza P r o v i n c e , Kenya 129 F i g u r e 7. S a r a d i d i C l i n i c 137 F i g u r e 8. The O r g a n i z a t i o n a l Development o f the S a r a d i d i R u r a l Health Development P r o j e c t 141 F i g u r e 9. S o c i a l O r g a n i z a t i o n of the S a r a d i d i R u r a l Health Development P r o j e c t 147 F i g u r e 10. Members of Ex e c u t i v e Committee [EC) 150 F i g u r e 11. Community Health Workers (CHWs) 178 F i g u r e 12. S i t e of Nangina Community Health Programme, Busia D i s t r i c t , Western P r o v i n c e , Kenya 208 F i g u r e 13. Nangina H o s p i t a l 211 F i g u r e 14. The O r g a n i z a t i o n a l Development of the Nangina Community Health Programme 215 xi -F i g u r e 15. S o c i a l o r g a n i z a t i o n of the Nangina Community Health Programme 232 F i g u r e 16. Community Health Worker (CHS) T r a i n e r 240-1 F i g u r e 17. Community Hea l t h Worker (CHW) Monthly Meeting 267 - - -'Xii.i — ABBREVIATIONS AMREF A f r i c a n M e d i c a l and fiesearch Foundation ( i n c o r p o r a t i n g E a s t A f r i c a n F l y i n g Doctor S e r v i c e s ) CBHC Community-Based Health Care CCGs C h r i s t i a n Community Groups (Nangina) CHWs community H e a l t h Workers CHW-SU Community H e a l t h Worker - Support U n i t (AMREF sponsored) - > CPK Church of the P r o v i n c e o f Kenya ( S a r a d i d i ) CSW Community S o c i a l Worker (Nangina) DANIDA Danish I n t e r n a t i o n a l Development Agency EC E x e c u t i v e Committee (Saradidi) FHFE Family H e a l t h F i e l d Educator ( M i n i s t r y of H e a l t h , Nangina) FPIA Family P l a n n i n g I n t e r n a t i o n a l A s s i s t a n c e (Saradidi) GOK Government of Kenya ( M i n i s t r y o f Health) IEF I n t e r n a t i o n a l Eye Foundation (Saradidi) IRH-FP I n t e g r a t e d R u r a l Health - Family P l a n n i n g S e r v i c e s ( M i n i s t r y of Health) IRHS I n t e g r a t e d R u r a l Health S e r v i c e s ( M i n i s t r y of Health) KCN Kenya Community Nurse ( M i n i s t r y of Health) MCH/FP Maternal C h i l d Health / Family Planning ( M i n i s t r y of Health, S a r a d i d i , and Nangina) MOH M i n i s t r y of H e a l t h NAFW N u t r i t i o n A i de F i e l d Worker (Nangina) NCHP Nangina Community Health Programme - xi'i'i -NGO PC PD PHAs PHC JJHDP EHDP RHTCs SDDMS SIDA SRHDP UNICEF US AID VHCs VHsTH VHW WHO Non-Government organized P r o j e c t Committee (Saradidi) P r o j e c t D i r e c t o r (Saradidi) P u b l i c Health A i d e s (Nangina) Primary H e a l t h Care (the l a b e l used by HHO/UNICEF f o r CBHC) Rura l Health Development P r o j e c t [ M i n i s t r y of Health) R u r a l Health Development P r o j e c t ( M i n i s t r y of Health) R u r a l H e a l t h T r a i n i n g Centres ( M i n i s t r y of Health) Senior Deputy D i r e c t o r of Medical S e r v i c e s ( M i n i s t r y of Health) Swedish I n t e r n a t i o n a l Development A u t h o r i t y S a r a d i d i R u r a l Health Development P r o j e c t United Nations I n t e r n a t i o n a l C h i l d r e n ' s Emergency Fund United S t a t e s Agency f o r I n t e r n a t i o n a l Development ( M i n i s t r y of H e a l t h , S a r a d i d i ) V i l l a g e H e a l t h Committees [Saradidi) V i l l a g e H e l p e r s Towards Health (nyainrerua, S a r a d i d i ) V i l l a g e H e a l t h Worker (used i n t e r c h a n g e a b l y with CHW) World Health O r g a n i z a t i o n - xlv_ -PREFACE The s u b j e c t of t h i s t h e s i s i s 'community-based h e a l t h c a r e ' (CBHC) , As a key-phrase made popular a t the Alma-Ata Conference, CBHC (or Primary Health Care) i s c u r r e n t l y held to be the nec e s s a r y , and only a v a i l a b l e s t r a t e g y f o r " a c h i e v i n g h e a l t h f o r a l l by the year 2000!" Yet i n t e r p r e t e d as i t has been i n a wide v a r i e t y of s o c i a l and c u l t u r a l c o n t e x t s , CBHC has emerged as a symbolic g l o s s f o r a broad spectrum of meanings and understandings. The aim and o b j e c t i v e of t h i s t h e s i s i s t o explore these d i f f e r e n c e s i n p h i l o s o p h i e s of h e a l t h care d e l i v e r y , and i n p a r t i c u l a r , to examine how r e p r e s e n t a t i v e h e a l t h care o r g a n i z a t i o n s i n the Republic of Kenya have responded to the c a l l f o r 'community-based h e a l t h c a r e . • I n t e r e s t i n g l y enough, t h i s e p i s t e m o l o g i c a l f o c u s developed out of a problem of a p p l y i n g an a n t h r o p o l o g i c a l p e r s p e c t i v e i n a h e a l t h c a r e s e t t i n g . While employed as Medi c a l A n t h r o p o l o g i s t i n the Rural H e a l t h Development P r o j e c t ( M i n i s t r y of H e a l t h headguarters, N a i r o b i , Kenya), I soon r e a l i z e d t h at the CBHC problems f a c e d by h e a l t h care planners and policy-makers were o r g a n i z a t i o n a l i n nature. "How i s i t p o s s i b l e , " they were a s k i n g : (i) " t o i n i t i a t e c u l t u r a l l y a p p r o p r i a t e CBHC programmes;" ( i i ) "to s o l i c i t the p a r t i c i p a t i o n and involvement of community members;" ( i i i ) " t o a r t i c u l a t e the planned CBHC programmes — which would emphasize d i s e a s e p r e v e n t i o n and h e a l t h promotion — with s t a t i c h e a l t h care f a c i l i t i e s p r o v i d i n g c l i n i c a l and c u r a t i v e c a r e ; " and (iv) " t o s u s t a i n these programmes over t i m e ? " During the f i f t e e n months that I worked f o r the M i n i s t r y of Health, I was g i v e n the r e s p o n s i b i l i t y to study ( in, §i£H) d i f f e r e n t models o f CBHC programmes. On the b a s i s of i n f o r m a t i o n gathered on these CBHC programmes [ r e c o n s t r u c t e d i n CBHC case p r o f i l e s ) , i t was f e l t t h a t an a p p r o p r i a t e model f o r a n a t i o n a l CBHC programme co u l d be for m u l a t e d . However, an emergent model f o r a n a t i o n a l CBHC programme never m a t e r i a l i z e d . The o r g a n i z a t i o n a l model f i n a l l y proposed by u p p e r - l e v e l managers within the M i n i s t r y of He a l t h r e f l e c t e d e x i s t i n g b u r e a u c r a t i c and o r g a n i z a t i o n a l r e a l i t i e s . I n many r e s p e c t s , t h i s CBHC p r o p o s a l p h i l o s o p h i c a l l y c o n t r a d i c t e d the requirements f o r CBHC agreed upon by the i n t e r n a t i o n a l h e a l t h care community (in p a r t i c u l a r , WHO and UNICEF). The M i n i s t r y Of Health's p o s i t i o n was, n o n e t h e l e s s , q u i t e understandable i f i n t e r p r e t e d i n terms of o r g a n i z a t i o n a l and s i t u a t i o n a l r e l e v a n c e s . Furthermore, the e p i s t e m o l o g i e s of CBHC generated i n oth e r , non-government org a n i z e d programmes c o u l d be s i m i l a r l y e x p l a i n e d . These r e f l e c t i o n s and o b s e r v a t i o n s of o r g a n i z a t i o n a l - e p i s t e m o l o g i c a l correspondences generated the problem of t h i s t h e s i s . - xv "T -When i t came to e x p l o r i n g the lineaments of t h i s r e s e a r c h problem, I was faced with a methodological dilemma. On the one hand, I wanted to expose the l a r g e r p i c t u r e of CBHC programmes i n the R e p u b l i c of Kenya (a macro-view); on the in o t h e r hand, I needed t o show ho w A s i n g u l a r CBHC s i t u a t i o n s (a micro-view) , e p i s t e m o l o g i e s of h e a l t h care t h a t are p o s i t e d r e f l e c t o r g a n i z a t i o n a l r e l e v a n c e s [ f o r example, b u r e a u c r a t i c , e x p a t r i a t e , t r i b a l , c l a n , community, or p e r s o n a l r e a l i t i e s ) . I f t h i s combined macro-micro view of CBHC programmes was to be achieved, i t would be p o s s i b l e to e l u c i d a t e some of the comparative d i f f e r e n c e s between CBHC programmes i n the R e p u b l i c of Kenya. F i r s t of a l l , I dec i d e d t o employ a case study method to_ accomplish these purposes. S e l c t i n g from a t o t a l l i s t of s i x t e e n CBHC programmes o p e r a t i n g at that time, I reduced the l i s t t o three f a m i l a r , and manageable c a s e s . These cases were r e p r e s e n t a t i v e of government, m i s s i o n - h o s p i t a l , and independent approaches towards CBHC, and are; the M i n i s t r y of Health (Case 1), the S a r a d i d i Rural Health; Development P r o j e c t (Case 2 ) , and the Nangina Community H e a l t h Programme (Case 3 ) . Secondly, i n order to e f f e c t i v e l y d i s p l a y the r e l a t i o n s h i p between e p i s t e m o l o g i e s and o r g a n i z a t i o n a l r e l e v a n c e s w i t h i n and between programmes, I decided t o e l i m i n a t e ethnographic d e t a i l . T h i s t a c t i c p e r mitted the p r i n c i p a l f o cus on o r g a n i z a t i o n a l elements i n the separate CBHC s t u d i e s (with an emphasis on s t r u c t u r e , - x,vi i — s o c i a l r e l a t i o n s , c o n s t r a i n t s , and processes of s o c i a l c o n s t r u c t i o n ) , and the e p i s t e m o l o g i e s , awarenesses, and t r u t h s p r e d i c a t e d on these r e a l i t i e s . Since t h i s i s a t h e s i s on epistemology and the philosophy of understanding, t h e r e i s no systematic b a s e l i n e f o r comparison; t h a t i s , these comparisons are not based on economic, p o l i t i c a l , t y p o l o g i c a l , and even s t a t i s t i c a l v a r i a b l e s . The comparisons t h a t a re made a r e those of epistemology. ks such, I have u t i l i z e d a q u a l i t a t i v e approach i n t h i s e x p l o r a t i o n i n t o the e p i s t e m o l o g i e s of h e a l t h c a r e . The e p i s t e m o l o g i c a l systems e l i c i t e d were,, with the e x c e p t i o n o f the M i n i s t r y of Hea l t h , not p r e d i c t a b l e ; i n s t e a d of b u r e a u c r a t i c and p r o f e s s i o n a l c o n s t r a i n t s , the other p h i l o s o p h i e s of h e a l t h c a r e were p r e d i c a t e d on i s s u e s of l e a d e r s h i p , movements towards the r e v i t a l i z a t i o n of t r a d i t i o n a l p r a c t i c e s , r e l i g i o u s r e v i v a l movements, and comprehensive community development e f f o r t s . The fieIdwork methods u t i l i z e d i n the g a t h e r i n g of i n f o r m a t i o n i n c l u d e d : p a r t i c i p a n t o b s e r v a t i o n [and ob s e r v a t i o n s made i n p a r t i c i p a t i o n a t work); i n t e r v i e w s [ s i n g l y , and i n groups) with a d m i n i s t r a t o r s . Community Health workers, community l e a d e r s , and other CBHC p a r t i c i p a n t s ; and the g a t h e r i n g and c o m p i l a t i o n of programme r e p o r t s , documents and p r o p o s a l s . T h e o r e t i c a l l y , t h e r e are three s c h o o l s o f thought that are brought t o bear on the problem of t h i s t h e s i s : phenomenology (and the s o c i o l o g y of knowledge) ,. s t r u c t u r a l i s m , and symbolic ( c r i t i c a l , and/or d i a l e c t i c a l ) anthropology. The s o c i o l o g i s t s of knowledge argue t h a t persons i n s o c i e t y c o n s t r u c t t h e i r own worlds of meaning and symbols; Berger and luckmann (1966) separate t h i s process of c o n s t r u c t i o n i n t o the three moments of e x t e r n a l i z a t i q n , o b j e c t i v a t i o n , and i n t e r n a l i z a t i o n . In t h i s t h e s i s , 1 separate the process of c o n s t r u c t i n g 'community-based h e a l t h c a r e ' (CBHC) programmes i n t o the t h r e e d i a l e c t i c a l moments of c o n c e p t u a l i z a t i o n , o r g a n i z a t i o n , and management. Since CBHC i s exp e r i e n c e d as an 'event' t h a t c r i t i c a l l y t e s t s e x i s t i n g h e a l t h care s t r a t e g i e s , the framework of s t r u c t u r a l i s m i s i n f o r m a t i v e i n determining the e p i s t e m o l o g i c a l r e l e v a n c e s that have emerged i n i t s development. Some of these i s s u e s are c o n s t i t u t e d i n r e l a t i o n s between: an u r b a n / r u r a l a l l o c a t i o n of h e a l t h care r e s o u r c e s , s a l a r i e d / v o l u n t e e r h e a l t h care workers, m o d e r n / t r a d i t i o n a l i n f l u e n c e s , complex/subsistence economic standards, and c u r a t i v e / p r e v e n t i v e h e a l t h c a r e emphases. L a s t l y , the t h e o r e t i c a l c o n t r i b u t i o n of symbolic anthropology i s u t i l i z e d t o e x p l i c a t e the experience of Community He a l t h Workers (CHWs) i n these t h r e e CBHC programmes. Many of the u n d e r l y i n g t e n s i o n s , dilemmas, and p o t e n t i a l i t i e s t h a t emerge i n the v a r i o u s CBHC programmes are r e f r a c t e d i n the person and work of the CHWs. On the one hand, these t e n s i o n s l i m i t and c o n s t r a i n the work of the CHW; on the other hand, i t i s i n the a c t i o n s , i n t e n t i o n s , , and c r e a t i v e p o t e n t i a l of i n d i v i d u a l s that CBHC programmes can develop i n t o e f f e c t i v e and i n n o v a t i v e programmes. The, t h e o r e t i c a l d i s t i n c t i o n t h a t i s made between 'person* and • i n d i v i d u a l ' i s i n s t r u c t i v e i n t h i s s i t u a t i o n . For example, i n peasant s i t u a t i o n s , •betwixt-and-between* s u b s i s t e n c e and complex s o c i a l o r d e r s , CHWs are compelled t o a c t as •persons' d e f e r r i n g to the moral requirements of one system over that of the o t h e r ; a l t e r n a t i v e l y , as ' i n d i v i d u a l s ' [Burridge 1979) persuaded by other r e l e v a n c e s and t r u t h s , they are capable of t r a n s c e n d i n g e x i s t i n g moral t e n s i o n s i n the work t h a t they do. •Worthwhileness' c o n t a i n s i n one word the images, metaphors, and g o a l s t h a t motivate the CHWs i n each of the thre e case s t u d i e s . In each case study, the image of worthwhileness t h a t emerges encapsulates the e p i s t e m o l o g i c a l awarenesses and t r u t h s o f t h e i r s i t u a t i o n ^ and r e f l e c t s the p o s i t i o n of the CHW i n the o r g a n i z a t i o n of the CBHC programme. These d i f f e r e n c e s a l s o r e f l e c t the 'open* and/or • c l o s e d ' p o s s i b i l i t i e s o f t h e i r p o s i t i o n , and are c h a r a c t e r i z e d by: a ' p r o f e s s i o n a l ' image of worthwhileness [the M i n i s t r y of H e a l t h ) ; a ' p r o g r e s s i v e ' image of worthwhileness [the S a r a d i d i R u r a l H e a l t h Development P r o j e c t ) ; and a • s p i r i t u a l * image o f worthwhileness (the Nangina Community H e a l t h Programme). F i n a l l y , I would l i k e to take t h i s o p p o r t u n i t y to thank the i n d i v i d u a l s who have guided and supported me i n t h i s endeavour. I am p e r s o n a l l y indebted t o many. I h i i e i t i s i m p o s s i b l e t o l i s t a l l of the f a m i l i e s , groups, community l e a d e r s , departments, and i n d i v i d u a l s who have a s s i s t e d me i n one way or another, t h e i r c o n t r i b u t i o n i s g r e a t l y a p p r e c i a t e d ; I am honoured t o know and to have known them. I s i n c e r e l y thank Dr. Kenelm Burridge [my t h e s i s s u p e r v i s o r ) f o r h i s guidance and support d u r i n g the e x p l o r a t i o n and i n t e r p r e t a t i o n of t h i s r e s e a r c h problem. His c o n t r i b u t i o n has been i n v a l u a b l e . I a l s o thank Dr. Nancy Waxier-Morrison and Dr. E l v i Whittaker (members of my t h e s i s committee) f o r i n s i g h t f u l and c r i t i c a l comments made du r i n g the course of t h i s t h e s i s preparation._ For a t t e n d i n g t o numerous a d m i n i s t r a t i v e d e t a i l s on my b e h a l f , I thank Joanne A l l a n i n the Graduate O f f i c e . I a l s o acknowledge with g r a t i t u d e the f i n a n c i a l a s s i s t a n c e awarded t o me from the F a c u l t y of Graduate S t u d i e s , i n p a r t i c u l a r , the T i n a and M o r r i s Wagner S p e c i a l S c h o l a r s h i p (1979-1980) and the H.R. Macmillan Family F e l l o w s h i p s (1980-1982). The twenty-one months t h a t I spent i n the Republic of Kenya were, without q u e s t i o n , e x p e r i e n t i a l l y r i c h and p r o d u c t i v e . I thank the many Kenyan and e x p a t r i a t e c o l l e a g u e s and f r i e n d s who made t h i s p o s s i b l e ; i n p a r t i c u l a r , Dan and Margaret Kaseje, H a r o l d and Nancy Fehderau, J o e l and Lucy Janzen, Roy and Betty S h a f f e r , Pat Adams, Paul Bennel, E l a i n e Feldman, and Bruce S c o t t . - xx-ii -The Development Co-Operation O f f i c e o f the Swedish Embassy — and i n p a r t i c u l a r C e c e l i a Gjerdrum — made p o s s i b l e my working as Medical A n t h r o p o l o g i s t i n the M i n i s t r y of Health. I g r a t e f u l l y acknowledge t h e i r f i n a n c i a l support and a s s i s t a n c e . I a l s o thank the O f f i c e of the P r e s i d e n t f o r o f f i c i a l "Research C l e a r a n c e " (Ref. No. NCST/SEC/4300.313) . At the M i n i s t r y o f H e a l t h , I would l i k e t o thank Drs. S. Kanani and Maneno; I am a l s o p e r s o n a l l y g r a t e f u l t o Finn Bennike, Steve and Ann F e t t n e r , Dr. Ingemar Gahnstedt, Gene Howard, and Sam Obiero. During the course of my f i e l d w o r k i n Kenya I v i s i t e d numerous CBHC programmes. I am most g r a t e f u l t o the many f r i e n d s who made my s t a y i n each of these r u r a l s e t t i n g s a r i c h and rewarding e x p e r i e n c e . I n p a r t i c u l a r , I would l i k e t o thank: Mama Dan, Henry Ochieng, Tanga Audi, and the many nyamrerua (at S a r a d i d i ) ; S i s t e r Dr. Leda Liboon, the M e d i c a l M i s s i o n S i s t e r s , Father N. Konings, and F r e d e r i c k onyango (at Nangina); Dr. Andrew and Cass Boddam-Whetham and Dr. Geoff and Dorothy I r v i n e (at Chog o r i a ) ; S i s t e r s Margaret B a i l e y and Ma t t i e T o l l e y (at Maua); S i s t e r G i l l H o r s f i e l d (at K i s i i ) ; and G e r a l d i n e Huising (at Machakos). In the f i n a l p r e p a r a t i o n of t h i s t h e s i s , I would l i k e to thank Sue Schenk and Aruna S r i v a s t a v a foe d i l i g e n t and e f f i c i e n t work t y p i n g . F i n a l l y , I would l i k e t o thank R i t a , my wife, f o r her c o n t i n u i n g l o v e and f r i e n d s h i p ; through the d i s r u p t i v e p e r i o d s of w r i t i n g , she has remained a c o n s t a n t source of support and i n s p i r a t i o n . To my parents, Waiter and F r i e d a Willms, I am profoundly g r a t e f u l f o r t h e i r l o v e and support i n a venture they have not always understood; I d e d i c a t e t h i s t h e s i s to them. X X I V I -Chapter I INTRODUCTION 1-1 THE ANTHROPOLOGICAL PROBLEM The problem of t h i s t h e s i s i s t o e x p l i c a t e e t h n o g r a p h i c a l l y the ex p e r i e n c e and process of accomplishing "community-based h e a l t h c a r e " (CBHC) programmes. An i n c r e a s i n g l y popular n o t i o n i n the c u l t u r e of i n t e r n a t i o n a l h e a l t h care o r g a n i z a t i o n s , "community-based h e a l t h c a r e " (CBHC) — the p r e f e r r e d l a b e l i n Kenya, yet a l s o synonymously known as "primary h e a l t h c a r e " (PHC) — has advanced as a key-phrase 1 i n f o r m i n g p o l i c y makers, h e a l t h c a r e p l a n n e r s , and a d m i n i s t r a t o r s committed t o p r o v i d i n g comprehensive h e a l t h care coverage f o r those persons the most p e r i p h e r a l l y s i t u a t e d to h e a l t h c a r e f a c i l i t i e s . Yet u n l i k e the c u r a t i v e f o c u s of a l r e a d y e s t a b l i s h e d f a c i l i t i e s , CBHC emphasizes education towards d i s e a s e p r e v e n t i o n , h e a l t h promotion, and f a m i l y planning i n the community, with necessary r e f e r r a l s to the e s t a b l i s h e d i n f r a s t r u c t u r e of c l i n i c s , d i s p e n s a r i e s , h e a l t h c e n t r e s , and h o s p i t a l s . In three case s t u d i e s , I seek to c o n s t r u c t the t o t a l s i t u a t i o n of programmes i n "community-based h e a l t h c a r e " (CBHC) as they are c o n c e p t u a l i z e d , implemented, and managed i n v a r i o u s h e a l t h care domains i n the R e p u b l i c of Kenya (see F i g u r e 1). - 1 -F i g u r e ! . Kenya 2 Adapted from: The World Bank, Kenya: P o p u l a t i o n and Development (Washington, D.C.: Development Economics Department, E a s t A f r i c a Country Programs Department, The World Bank, 1980), Regions and D i s t r i c t s Map. 3 I argue that because of the d i f f e r e n c e s i n understanding of what ' h e a l t h , ' ' h e a l t h c a r e , * and 'community' means i n each of the s o c i a l domains where CBHC emerges as a p o s s i b l i t y , the notion of CBHC i s per c e i v e d , i n t e r p r e t e d , and transformed a c c o r d i n g l y , And yet i n a l l s i t u a t i o n s , the promise of CBHC i s a prominent event. I t breaks i n on the p a r t i c u l a r community or o r g a n i z a t i o n with economic, p o l i t i c a l , and i d e o l o g i c a l s i g n i f i c a n c e : to the M i n i s t r y of Health (see Chapter 2 ) , i t s acceptance means 'money' and the c o n t i n u i n g promise of a i d - r e l a t e d f i n a n c i a l s u p port; to the Luo community of S a r a d i d i (see Chapter 3) i t augurs f o r a r e l e v a n t and comprehensive development s t r a t e g y ; while f o r the Nangina M i s s i o n p a r i s h i o n e r s (see Chapter 4), the emergence of CBHC i n the r u r a l c l a n - b a s e d communities prov i d e s an avenue f o r a c t u a l i z i n g t h e i r renewed sense of s e l f i n s e r v i c e of o t h e r s . These d i f f e r e n c e s i n accomodating t o the s t r a t e g y of CBHC w i l l be e x p l a i n e d e p i s t e m o l o g i c a l l y through the p r e s e n t a t i o n of the f o l l o w i n g three ethnographic c a s e s : (1) the bureaucracy of the M i n i s t r y of gea,lth; headquarters i n N a i r o b i , Kenya; (2) the s i t u a t i o n of an independent, r u r a l - b a s e d , peasant, Luo community i n t h e i r c o n s t r u c t i o n of the S a r a d i d i R u r a l Health Development P r o j e c t ; and 4 (3) the exp e r i e n c e of the Nang.in.a_ Community Health P£29£amme ~~ a programme i n s p i r e d by a mission and h o s p i t a l and whose i n f l u e n c e i s both r e l i g i o u s ( C h r i s t i a n ) and b i o m e d i c a l (through the p r o v i s i o n of modern, c l i n i c a l , h e a l t h care f a c i l i t i e s ) but which r e l i e s on t r a d i t i o n a l systems o f community support. These cases are s i g n i f i c a n t i n t h a t they address the qu e s t i o n : (i) How i s "community-based h e a l t h c a r e " (CBHC) p o s s i b l e ? Secondly, they are s u f f i c i e n t l y d i v e r s e and unique t o answer the question: ( i i ) What does "community-based h e a l t h c a r e " (CBHC) mean and how i s i t shaped by the p o l i t i c a l economy and i d e o l o g y of d i f f e r e n t i a l l y c o n s t r u c t e d s o c i a l - c u l t u r a l r e a l i t i e s ? But while the l a r g e r problems of t h i s t h e s i s a re to make evi d e n t t h i s process, the s p e c i f i c problem i s p r e d i c a t e d on these emerging p o s s i b i l i t i e s . For i t i s the Community H e a l t h Workers (CHWs) -- and those l i k e them — who, compelled to assume the c l o a k of t h e i r own i n d i v i d u a l i t y f i n d themselves i n the s o c i a l p o s i t i o n that e i t h e r permits o r d e t e r s the making of a CBHC programme. E i t h e r they a c t as p e r s o n s 2 who s u b s c r i b e t o the p r o f e s s i o n a l requirements, e x p e c t a t i o n s , and s t a t u s e s o f the o r g a n i z a t i o n that i n t e r v e n e s with i t s p l a n f o r CBHC (as i n the case of the M i n i s t r y of Health — see Chapter 2) , or i n n e g o t i a t i n g the 5 c o n t r a d i c t i o n s , o p p o s i t i o n s , and problems t h a t i n e v i t a b l y ensue i n the i n i t i a t i o n of development programmes tran s c e n d them, and i n so doing mobilize the involvement and p a r t i c i p a t i o n of other community members. T h i s s u s t a i n e d and c o n t i n u i n g i n t e r e s t i n the CBHC programme i s e x e m p l i f i e d i n the S a r a d i d i {Chapter 3) and Nangina cases (Chapter 4). How t h i s a r t i c u l a t i o n i s acomplished by Community Health Workers (CHWs) and why i t must be so i s the s p e c i f i c problem of t h i s study. For CBHC programmes to develop a u t h e n t i c a l l y and with the f u l l involvement of community members and t h e i r r e s o u r c e s , t h i s c o n t r i b u t i o n of the CHWs i s necessary — and with them the support system of P r o j e c t D i r e c t o r s , v i l l a g e e l d e r s , l e a d e r s , t r a i n e r s , nurses, and community members. 1.2 THE LANGUAGE, SYMBOLISM, AND CULTURE OF "COMMUNITY-BASED HEALTH CARE" 1.2.1 D e f i n i t i o n s and Proposals of H HO and UNICEF ' A recent p u b l i c a t i o n of the WHO i n d i c a t e s t h a t ; despite an i n t e r n a t i o n a l l y agreed d e f i n i t i o n , the term "primary h e a l t h c a r e " i s being a p p l i e d around the world to a v a r i e t y of r e a l i t i e s and even of concepts. ? T h i s s i t u a t i o n i s confirmed i n our three cases, which suggests t h a t an examination of the processes through which CBHC programmes are implemented must be viewed i n l i g h t of the e p i s t e m o l o g i c a l r e l e v a n c e s which determine the outcome o f these a c t i v i t i e s . But then, what i s Primary H e a l t h Care (PHC) or "community-based h e a l t h c a r e " (CBHC)? In statements made by the D i r e c t o r - G e n e r a l o f the World He a l t h O r g a n i z a t i o n (WHO) and the E x e c u t i v e - D i r e c t o r of the United Nations I n t e r n a t i o n a l C h i l d r e n ' s Emergency Fund (UNICEF), Primary Health Care i s d e f i n e d as; e s s e n t i a l h e a l t h care made u n i v e r s a l l y a c c e s s i b l e t o i n d i v i d u a l s and f a m i l i e s i n the community by means a c c e p t a b l e to them, through t h e i r f u l l p a r t i c i p a t i o n and at a co s t t h a t the community and coun t r y can a f f o r d . I t forms an i n t e g r a l p a r t both of the country's h e a l t h system of which i t i s the nucleus and of the o v e r a l l s o c i a l and economic development o f the community. 4 Furthermore, Primary H e a l t h Care i s co n s i d e r e d to be: . . . the f i r s t l e v e l of c o n t a c t of i n d i v i d u a l s , the f a m i l y and the community with the n a t i o n a l h e a l t h system, b r i n g i n g h e a l t h care as c l o s e as p o s s i b l e to where people l i v e and work and c o n s t i t u t e s the f i r s t element of a c o n t i n u i n g h e a l t h care p r o c e s s . 5 While i n the con t e x t of developing c o u n t r i e s t h i s " f i r s t l e v e l of co n t a c t i n Primary Health Care (PHC) programmes i s with a person who p r o v i d e s disease p r e v e n t i o n and h e a l t h promotion s e r v i c e s , i t should be s t a t e d t h a t i t may imply (as i t tends t o connote i n the West) access t o the c l i n i c a l s e r v i c e s of a g e n e r a l p r a c t i o n e r . At Alma-Ata, U.S.S.R., i n September 1978, the p a r t i c i p a n t s o f the I n t e r n a t i o n a l Conference on Primary He a l t h Care — r e p r e s e n t i n g 134 n a t i o n s as w e l l as numerous government and non-government o r g a n i z a t i o n s — adopted a te n - p o i n t D e c l a r a t i o n and made 22 s p e c i f i c recommendations r e g a r d i n g the implementation of Primary Health Care programmes. 6 They a l s o agreed i n p r i n c i p l e t o c o o r d i n a t e 7 t h e i r e f f o r t s to achieve world-wide comprehensive h e a l t h care coverage through Primary Health Care (PHC). In subsequent meetings between government, non-government, and development agencies, they are c o n t i n u i n g t o formulate methods and c o n s t r u c t models f o r implementation that encourages c o l l a b o r a t i o n and i n t e g r a t i o n of s e r v i c e s . 7 The mandate f o r t h i s i n t e r n a t i o n a l task i s : . . . the attainment by a l l c i t i z e n s of the world by the year 2 0 0 0 o f a l e v e l of h e a l t h t h a t w i l l permit them t o l e a d a s o c i a l l y and ec o n o m i c a l l y p r o d u c t i v e l i f e . . . 8 I t r e i t e r a t e s the d e f i n i t i o n of ' h e a l t h ' adopted by the I n t e r n a t i o n a l Health Conference i n 1946, but with the a d d i t i o n of a c r i t i c a l time s c a l e : Health i s a s t a t e of complete p h y s i c a l , mental and s o c i a l w e l l - b e i n g and not merely the absence o f disease or i n f i r m i t y . 9 With the Alma-Ata agreement as a mandate f o r Primary Health Care or CBHC, how i s t h i s form of h e a l t h care s e r v i c e t o be implemented? A c c o r d i n g to r e p o r t s by the World Health O r g a n i z a t i o n (WHO), CBHC programmes a r e to be i n i t i a t e d i n such a way t h a t communities can be a f f o r d e d the op p o r t u n i t y to d i s p l a y s e l f - r e l i a n c e and s e l f - m o t i v a t i o n i n the i n i t i a t i o n , c o n s t r u c t i o n , and c o n t r o l of t h e i r CBHC programme: . . . the people have the r i g h t and duty t o p a r t i c i p a t e i n d i v i d u a l l y and c o l l e c t i v e l y i n the planni n g and implementation of t h e i r h e a l t h c a r e . Primary Health Care . . . r e g u i r e s and promotes maximum community and i n d i v i d u a l s e l f - r e l i a n c e and p a r t i c i p a t i o n i n the planning, o r g a n i z a t i o n , o p e r a t i o n and c o n t r o l o f primary h e a l t h c a r e . 3 making the f u l l e s t use of l o c a l , n a t i o n a l , and other a v a i l a b l e r e s o u r c e s , and to t h i s end develops through a p p r o p r i a t e education the a b i l i t y of the communities to p a r t i c i p a t e . ... . While these statements seem to suggest that a CBHC programme i s an i s o l a t e d , p r i n c i p a l l y community-based e x p e r i e n c e , i n a c t u a l i t y t h i s i s never the case. For au adequate p r o v i s i o n of h e a l t h c a r e coverage, i t i s necessary f o r community members to seek out and depend on the p r o f e s s i o n a l , medical a s s i s t a n c e t h a t may be o u t s i d e t h e i r own p a r o c h i a l sphere of understanding and e x p e r i e n c e . For example, i n the treatment of c r i t i c a l i l l n e s s c a s e s (eg. o b s t r u c t e d pregnancies, c h o l e r a , c e r e b r a l m a l a r i a , e t c . ) , the Community Health Worker (CHW) would be r e q u i r e d to e s c o r t the p a t i e n t o u t s i d e the v i l l a g e to the n e a r e s t h o s p i t a l , o f t e n m i l e s away, so that the necessary c l i n i c a l care and a t t e n t i o n c o u l d be obta i n e d . T h i s r e a d i l y a v a i l a b l e i n f r a s t r u c t u r e of c l i n i c a l c are (with nurses, d o c t o r s , drugs, and l a b o r a t o r y s e r v i c e s ) i s an e s s e n t i a l requirement f o r an e f f e c t i v e CBHC approach: Primary H e a l t h Care . . . should be s u s t a i n e d by i n t e g r a t e d , f u n c t i o n a l and mutually s u p p o r t i v e r e f e r r a l systems, l e a d i n g t o the p r o g r e s s i v e improvement of comprehensive h e a l t h care f o r a l l , and g i v i n g p r i o r i t y t o those most i n need. . Primary H e a l t h Care i s e s s e n t i a l h e a l t h care based on p r a c t i c a l , s c i e n t i f i c a l l y sound and s o c i a l l y a c c e p t a b l e methods. 1 1 The development of the CBHC programmes e n t a i l s more than the e f f o r t s of any one community t o devise an a p p r o p r i a t e system of h e a l t h promotion and d i s e a s e p r e v e n t i o n a c t i v i t i e s . I n s t e a d , i t i n v o l v e s v i l l a g e and community o r g a n i z a t i o n s 9 merging with more complex o r g a n i z a t i o n s encompassing added p r o f e s s i o n a l and p o l i t i c a l demands. The net e f f e c t i s a d i a l e c t i c a l c o n s t r u c t i o n i n v o l v i n g d i f f e r i n g spheres of a u t h o r i t y , power, i n t e n t i o n s , and experience. The Alma-Ata D e c l a r a t i o n does not adequately address the ensuing problems when i t s t a t e s : Primary H e a l t h Care r e f l e c t s and evol v e s from economic c o n d i t i o n s , s o c i o c u l t u r a l and p o l i t i c a l c h a r a c t e r i s t i c s o f the country and i t s communities and i s based on the a p p l i c a t i o n of the r e l e v a n t r e s u l t s of s o c i a l , b i o m e d i c a l and h e a l t h s e r v i c e s r e s e a r c h and p u b l i c h e a l t h e x p e r i e n c e , 1 2 So while a l l u d i n g to the complexity of s o c i a l , c u l t u r a l , economic, p o l i t i c a l , and e p i s t e m o l o g i c a l f o r c e s that converge i n the c o n s t r u c t i o n of CBHC programmes, i t understandably a v o i d s i d e n t i f y i n g the u n d e r l y i n g r e l a t i o n s which causes the f r e q u e n t breakdown i n CBHC programmes. The task o f the World H e a l t h O r g a n i z a t i o n (WHO) i s p o l i t i c a l i n na t u r e : t o persuade and motivate member s t a t e s to the s i g n i f i c a n c e of the CBHC s t r a t e g y . To accomplish t h i s noble o b j e c t i v e o f " h e a l t h f o r a l l by the year 2000," the WHO l e g i t i m a t e s i t s c a l l with r e f e r e n c e t o : "the unique m a n i f e s t a t i o n of h e a l t h care s o l i d a r i t y , " the f a c t t h a t CBHC i s "an i n t e g r a l part o f the o v e r a l l development of s o c i e t y , " and that i t ought t o be accomplished " i n the s p i r i t of s o c i a l j u s t i c e . " 1 3 10, 1.2.2 Problems I d e n t i f i e d i n the Implementation and Haaaatiejit of CBHC Programmes In i t s r e l a t i v e l y s h o r t h i s t o r y as an i n t e r n a t i o n a l h e a l t h care movement, CBHC programmes have experienced numerous problems a s s o c i a t e d with the implementation, and p a r t i c u l a r l y the c o n t i n u i n g management of the CBHC programmes. I t has been recorded^ f o r i n s t a n c e , t h a t "the scope and depth of community involvement are o f t e n d o u b t f u l " 1 4 and t h a t the community members and the Community He a l t h Workers (CHWs) themselves a r e unable t o remain i n t e r e s t e d i n the o b j e c t i v e s and g o a l s of the CBHC programme. T h i s f r e q u e n t l y occurs when the programme i s i n i t i a t e d from an agency, i n s t i t u t i o n , o r o r g a n i z a t i o n o u t s i d e the community, which a f t e r a couple of y e a r s of e n t h u s i a s t i c support withdraws, l e a v i n g the momentum t o community members themselves. For example, i n a CBHC programme i n s o u t h - c e n t r a l Cameroon t h a t was implemented by the U n i v e r s i t y of P i t t s b u r g h OCEAC ( O r g a n i s a t i o n de C o o r d i n a t i o n pour l a L u t t e contre l e s Endemies en A f r i g u e Centrale) with funds from USAID (the United S t a t e s Agency f o r I n t e r n a t i o n a l Development), only a few of the " v i l l a g e h e a l t h committees" i n t i t i a t e d by " i t i n e r a n t h e a l t h workers" remained a c t i v e a f t e r the P r o j e c t withdrew i t s support: By the most generous estimate only a t h i r d (15/43) of the committees remain. Of these, only three can be s a i d to be a c t i v e , the remaining twelve being i n v a r y i n g degrees of i n a c t i v i t y . 1 5 11 In another case — t h a t of the E t h i o p i a n Gondar Health C o l l e g e " p e r i p h e r a l h e a l t h workers" p r o j e c t — community members were never c o n s u l t e d about the implementation of a CBHC programme i n t h e i r area. Not s u r p r i s i n g l y , when the C o l l e g e withdrew i t s support, the CBHC p r o j e c t c o l l a p s e d . In t h i s i n s t a n c e , the h e a l t h workers, f a c i n g s t i f f c o m p e t i t i o n from p r i v a t e i n d i v i d u a l s who o f f e r i n d i s c r i m i n a t e i n j e c t i o n s t o anyone who can pay f o r them and forced to t h i n k o f t h e i r own l i v e l i h o o d , succumbed to the temptation and themselves entered the b u s i n e s s . 1 6 These are j u s t two cases of many where CBHC programmes are threatened when i n i t i a t e d and implemented u n i l a t e r a l l y . In these i n s t a n c e s , there i s no d i a l o g u e , communication, or encounter between the o r g a n i z a t i o n t h a t should a c t as a p r o f e s s i o n a l support s t r u c t u r e i n the CBHC programme and the community which i s expected t o be s e l f - r e l i a n t and i n v o l v e d i n the a m e l i o r a t i o n of i t s own "unmet f e l t needs." For h e a l t h care planners i n the business of implementing a p p r o p r i a t e CBHC programmes, the problem s t i l l remains: How i s i t p o s s i b l e t o implement mutually s u p p o r t i v e systems of h e a l t h care between the c l i n i c a l i n f r a s t r u c t u r e and the " s e l f - r e l i a n t " community i n a CBHC programme? 1.2.3 TJ_e Impinging. S i t u a t i o n of the Community H e a l t h Workers (CHWs) Dr. D. B a n e r j i , who i s we l l - v e r s e d i n the complexity of t h i s problem, speaks of the need f o r " d e m o c r a t i s a t i o n " of CBHC programmes: 12 Democratisation of a community and involvement of democratic i n s t i t u t i o n s form th_e. c o r n e r s t o n e o f community. E a r t i c i g a t i o n . An approach i n which a community i s made to get i n v o l v e d through a d i c t a t e from above thus becomes the very a n t i t h e s i s of what i s i m p l i e d i n the philosophy of primary h e a l t h c a r e , 1 7 While "democratisation ,» i n CBHC i s the i d e a l , i t i n f r e g u e n t l y happens i n r e a l i t y . , Planners and a d m i n i s t r a t o r s embark on 'missions' o f CBHC with t h e i r own p e r s p e c t i v e of what i s " e s s e n t i a l " i n h e a l t h care s e r v i c e s . H h i l e there may be o v e r l a p between what i s proposed by i n i t i a t o r s and what i s expected i n terms o f " f e l t needs" by the community, there i s g e n e r a l l y an area of o p p o s i t i o n , c o n t r a d i c t i o n , and ambiguity i n the process of implementation. Those persons that are compelled t o work "betwixt and between" these f o r c e s of t r a d i t i o n a l and imposed, p r o f e s s i o n a l a u t h o r i t y , experience the dilemma most a c u t e l y : . . on the one hand, CHWs belong to and are r e s p o n s i b l e to the community they serve. On the other hand, the l o c a l communities cannot by themselves p r o p e r l y guide and t r a i n CHWs i n p r e p a r a t i o n f o r t h e i r t e c h n i c a l t a s k s , as we l l as provide them with r e g u l a r s u p e r v i s i o n . . . . . . .. community h e a l t h workers have a d u a l a l l e g i a n c e — t o ser v e the community and the hea l t h s e r v i c e s . . . l B Community Health Workers (CHWs) o f t e n r e f l e c t these experiences of doubt and ambiguity. As l e a d e r s i n t h e i r own communities, they e i t h e r s e i z e the chance t o advance t h e i r own p e r s o n a l f o r t u n e s through the o p p o r t u n i t i e s a f f o r d e d i n a CBHC p r o j e c t , o r t r u e t o the experience of l i f e i n 13 community, t r a n s f o r m these b e n e f i t s u n s e l f i s h l y and a l t r u i s t i c a l l y on b e h a l f of the "community good." John H. Bryant concurs with t h i s assessment of the CHWs dilemma: Whereas income, p r e s t i g e , and perhaps a d e s i r e f o r e a s i e r jobs seemed important as m o t i v a t i n g f a c t o r s i n one country, a l t r u i s m and p r i d e and i n t e r e s t i n the community seemed t o be the f a c t o r s a t work i n a n o t h e r . 1 9 To accomplish the l a t t e r may r e g u i r e an element of charisma, but more i m p o r t a n t l y , the f o r t i t u d e , s t r e n g t h , and i n t e g r i t y t o f a c e the c o n t r a d i c t i o n s head on, and i n ex p e r i e n c i n g them, seek t o transcend and h o p e f u l l y r e s o l v e them. For the problems are many. While the o r g a n i z a t i o n which i n i t i a t e s a CBHC programme may make p r o v i s i o n f o r a predominantly " e d u c a t i v e " h e a l t h care programme ( i . e . , the di s s e m i n a t i o n o f f a m i l y planning, d i s e a s e p r e v e n t i o n , and h e a l t h promotion knowledge), the v i l l a g e s may be ex p e c t i n g drugs, a " l o c a l d o c t o r , " and the a d d i t i o n a l ; "modern" b e n e f i t s o f Western, c l i n i c a l care (see F i g u r e 2 ) . On the other hand, the Community H e a l t h Worker (CHW) who i s made to f e e l the o p p o s i t i o n of these impinging r e a l i t i e s , may experience r e s i s t a n c e i n another way. The v i l l a g e r s , having p r e v i o u s l y been promised " a s s i s t a n c e " by government m i n i s t r i e s i n h e a l t h c a r e , a g r i c u l t u r e , water, or e d u c a t i o n a l s e r v i c e s , may f e e l badly t r e a t e d — an experience o f c o g n i t i v e dissonance — and t h e r e f o r e refuse t o i n v o l v e themselves i n a development programme i n which they may p o s s i b l y be duped. A l t e r n a t i v e l y , they may be 14 F i g u r e 2. V o l u n t e e r Community H e a l t h Workers (CHWs) w e i g h i n g c h i l d r e n a t a temporary MCH c l i n i c based i n a r u r a l v i l l a g e . The CHWs a r e t r a i n e d by t h e Maua M e t h o d i s t H o s p i t a l Community-Based H e a l t h Care (CBHC) Programme, Meru D i s t r i c t , Kenya. Maternal Child Health (MCH) C l i n i c 15 s u s p i c i o u s f o r other reasons; they may be so h e a v i l y ensconced i n a t r a d i t i o n a l l y - b a s e d "popular h e a l t h c u l t u r e " 2 0 t h a t i t i s d i f f i c u l t t o i n c o r p o r a t e e f f e c t i v e l y the new techniques and p r i n c i p l e s with the o l d . 2 1 Then there are the problems of money; while they might be i n a p o s i t i o n to pay f o r an i n j e c t i o n or drug t h a t t a n g i b l y addresses t h e i r experience of b e i n g s i c k , what should they do f o r the CHW when he/she v i s i t s them i n t h e i r home and o f f e r s no cu r e , but simply a d v i s e s them on how to prevent t h a t s i c k n e s s from happening a g a i n , o r even suggests t h a t they can r e c t i f y and t r e a t i t themselves (e.g., the recommendation t o prepare i n the home the o r a l r e h y d r a t i o n f l u i d f o r cases of d i a r r h o e a and vomiting i n c h i l d r e n ) ? 2 2 And l a s t l y , are these CHWs accountable to an " e x t e r n a l " government or non-government agency, or are they p r i n c i p a l l y r e s p o n s i b l e to the community? These dilemmas are not only the experience of community members, but more immediately,, the CHWs who are expected t o work i n these s i t u a t i o n s . 2 3 They are the i n f o r m a l l e a d e r s 2 * who have the o r g a n i z a t i o n a l and m o t i v a t i o n a l s k i l l s to s u s t a i n i n t e r e s t i n the CBHC programme (see the experience of the Nangina and S a r a d i d i programmes i n Chapters 3 and 4) or c o n t r i b u t e t o i t s d i s o r g a n i z a t i o n . In t h i s t h e s i s , I r e s e a r c h an area i n medical anthropology t h a t has not been s u f f i c i e n t l y s t u d i e d . I examine the process through which CBHC programmes are 17 s o c i a l l y n e g o t i a t e d and accomplished i n the community, and r e l a t e t h i s work t o s i t u a t i o n a l l y - d e r i v e d v a l u e s and understandings — i . e . , the c u l t u r e and e p i s t e m o l o g i c a l r e a l i t y o f the community i n which CBHC takes p l a c e . I n so. doing I respond to George F o s t e r ' s recommendation when he say s : In Primary H e a l t h Care (PHC) programs g r e a t e r a t t e n t i o n needs t o be paid t o how a community i s mob i l i z e d and i t s f o r c e s brought t o bear on h e a l t h problems. T h i s means g r e a t e r formal a t t e n t i o n t o the form and q u a l i t y of formal and i n f o r m a l l e a d e r s h i p found i n communities where work i s to be d o n e . 2 5 In a d d i t i o n , i t i s e s s e n t i a l t o address the q u e s t i o n o f : . .... how to pre s e r v e l o c a l i n i t i a t i v e , i . e . , the d e l i c a t e balance t o be achieved between t e c h n i c a l a s s i s t a n c e and support of l o c a l l y generated e f f o r t In t h i s b o r d e r l a n d between h e a l t h s e r v i c e and community, the Community Hea l t h Workers (CHWs) not only r e f l e c t the dissonance of a t t i t u d e s , v a l u e s , and world view between these two domains ( d i s c u s s e d on page 13)^ but are i n a p o s i t i o n t o image and c o n s t r u c t unique p o s s i b i l i t i e s o f care i n s p i t e of the d i f f i c u l t i e s i n t r i n s i c to t h e i r p o s i t i o n . The d i f f e r e n t i a l l y - c o n s t r u c t e d e p i s t e m o l o g i e s t h a t determine thes e v a r i o u s CBHC programmes, and t h e i r r e l a t i o n s t o the wider i n f r a s t r u c t u r e s of government or non-government s e r v i c e s i s the p r o j e c t o f t h i s study. 18 1.3 IDEOLOGICAL BACKGROUND TO THE INTERVENTION OF CBHC AS A HEALTH CARE DEVELOPMENT STRATEGY There are many elements, recommendations, and p r i n c i p l e s of the CBHC programme t h a t overlap e x i s t i n g developmental s t r a t e g i e s i n the R e p u b l i c of Kenya. For example, the emphasis on development programmes i n the r u r a l a r e a s , v i l l a g e - b a s e d e f f o r t s , and s e l f - r e l i a n c e of community members i n the i n i t i a t i o n , implementation, and management of s e l f - h e l p programmes i s a l s o c h a r a c t e r i s t i c o f the Harambee movement (see 3.1 below). But here too, the problems t h a t emerge are p r e d i c a t e d on the i n a b i l i t y to r e c o n c i l e d i f f e r e n t i a l l y - b a s e d a u t h o r i t i e s and powers: f o r example, the system of government and b u r e a u c r a t i c c o n t r o l s impinging on community-based p o l i t i c a l e l i t e s ; 2 7 the f r u s t r a t i o n of community l e a d e r s i n t h e i r dependence on the government i n f r a s t r u c t u r e f o r f i n a n c i a l and p r o f e s s i o n a l support; and the d i f f i c u l t i e s t h a t occur i n the i n t e r f a c e of d i f f e r e n t i a l l y c o n s t r u c t e d economic systems ( t r a d i t i o n a l cum modern)., Because o f t h i s , the problems of s u s t a i n i n g the involvement and p a r t i c i p a t i o n of community members i s a shared experience of both harambee and CBHC programmes. Tq f u l l y understand the impact of CBHC i n present day development programmes i n Kenya, i t i s necessary t o c o n s i d e r the emergence of the CBHC st r a t e g y i n the co n t e x t of the harambee movement. 19 1.3.1 The "Harambee" Movement When Kenya a t t a i n e d I n t e r n a l Self-Government on June 1, 1963, Jomo Kenyatta gave the r a l l y i n g cry to the new n a t i o n , "harambee. " 2 a In K i s w a h i l i , harambee l i t e r a l l y means " p u l l t o g e t h e r , " 2 9 and i s p urported to d e r i v e from the work gang c r y "aaaaa - mbee! meaning ready - p u s h . " 3 0 Before Independence, the m o b i l i z i n g f o r c e was Uhuru meaning "freedom;" having a t t a i n e d t h a t , the task was to r e d r e s s the u nequitable s i t u a t i o n t h a t e x i s t e d between A f r i c a n and European, and b u i l d a more j u s t and e q u i t a b l e n a t i o n . Today, the s l o g a n of harambee i s widely used. Wr i t t e n on the country's s e a l as the n a t i o n ' s motto, i t symbolizes the need f o r s e l f - r e l i a n c e and community i n i t i a t i v e i n the development of the c o u n t r y . With the c u r r e n t government of D a n i e l arap Moi, the s l o g a n of Nyayo r e i t e r a t e s t h i s i m p e r a t i v e of harambee made famous by the Mzee (the " o l d man," Kenyatta) by f o l l o w i n g " i n h i s f o o t s t e p s . " I n many r e s p e c t s , the c a l l f o r harambee i s a p l e a f o r r e t u r n i n g t o t r a d i t i o n a l l y p r a c t i s e d systems of work, support, and c a r e . I t r e i n f o r c e s those c u l t u r a l l y - d e r i v e d n o t i o n s t h a t are s t i l l a p r i n c i p l e of community o b l i g a t i o n i n the r u r a l areas of Kenya: . , . . the Luo c a l l i t Konyir Kende, the Luhya obwasio, the Kamba Mwethia, the Kikuyu Nqwatio, and the Masai Ematonyok . . . 3 1 and i t i n v o l v e s the c o l l e c t i v e work i n v o l v e d i n c l e a r i n g , p l a n t i n g , and weeding gardens, b u i l d i n g houses or roads, and 20 now, the a c t i v i t y of c o n s t r u c t i n g s e l f - h e l p (harambee) s c h o o l s , community h a l l s , d i s p e n s a r i e s , and most r e c e n t l y i n s t i t u t e s of t e c h n o l o g y . 3 2 In c o l o n i a l days, the community o b l i g a t i o n of working i n the "work p a r t y " was turned i n t o a k i n d of " t a x a t i o n " i n human labour, a l l unemployed men were r e q u i r e d to work f o r approximately 24-60 days a year i n unpaid l a b o u r . 3 3 There i s a c l e a r d i s t i n c t i o n between t h i s k i n d of l a b o u r (which served the purposes of d e v e l o p i n g the i n f r a s t r u c t u r e of roads and r a i l r o a d s on b e h a l f of the c o l o n i a l government) and t h a t of a harambee p r o j e c t (which i s designed t o a m e l i o r a t e the f e l t - n e e d s of community, members). N e v e r t h e l e s s , t h e r e are s i m i l a r i t i e s i n t h a t the r e l a t i o n s h i p of "pushing and p u l l i n g " between government and r u r a l community i s not always complementary i n harambee p r o j e c t s . I n i t i a l l y , the government promised to match the i n i t i a t i v e s of r u r a l , peasant communities with funds or p r o f e s s i o n a l s e r v i c e s . For example, i f a community f e l t t h a t they needed a s c h o o l i n t h e i r l o c a t i o n , and with great r e s o u r c e f u l n e s s o r g a n i z e d the money and work to b u i l d the s c h o o l , they would expect the M i n i s t r y of E d u c a t i o n to p r o v i d e a t e a c h e r. a l t e r n a t i v e l y , they might b u i l d a dispensary and expect the government to p r o v i d e the drugs and community nurse. However, the post-independence response to the c a l l f o r harambee was so immediate and dramatic, t h a t the government was i l l - p r e p a r e d t o match the. 21 i n i t i a t i v e s of the hundreds of communities who attempted to "develop themselves." As a r e s u l t , there a r e hundreds of s c h o o l s , d i s p e n s a r i e s , and c l i n i c s 3 * t h a t have been p h y s i c a l l y c o n s t r u c t e d but are not i n use. They remain as t a n g i b l e reminders of the hard work, f r u s t r a t i o n , and d i m i n i s h i n g f a i t h i n a government that i s not always prepared to meet t h e i r needs. The o r d i n a r y c i t i z e n s or wananchi (in K i s w a h i l i ) are the ones who s u f f e r , making about 90% of the t o t a l c o n t r i b u t i o n s i n harambee p r o j e c t s . 3 5 To c o u n t e r a c t t h i s tendency, the government has i n t r o d u c e d the n o t i o n of " p a r t i c i p a t i v e c e n t r a l i s m . " R e q u i r i n g t h a t a p p l i c a t i o n s f o r haEaibee p r o j e c t s be channeled through c e n t r a l m i n i s t r i e s , the government i s attempting to c o o r d i n a t e g r a s s r o o t s development p r o j e c t s with the development p l a n s and s t r a t e g i e s of the O f f i c e of the P r e s i d e n t . A c c o r d i n g to G.K. K a r i i t h i , a Permanent S e c r e t a r y i n t h i s O f f i c e : The term i s meant to i n d i c a t e a system with a strong c e n t r a l l e a d e r s h i p and c o n t r o l , i n which there i s , n e v e r t h e l e s s , a very high degree of i n d i v i d u a l and group p a r t i c i p a t i o n by the people themselves. T h i s term i s not very f a r removed from Harambee, which i n i t s deepest r e f e r e n c e s , i s more than j u s t p u t t i n g up a h e a l t h c e n t r e . Harambee, or p a r t i c i p a t i v e c e n t r a l i s m , i s a t o t a l system which u n d e r l i e s our p o l i t i c a l , economic and s o c i a l p r o c e d u r e s . 3 6 In the f a c e of growing d i s c o n t e n t i n the r u r a l a r e a s , the government has attempted to r e g a i n i t s b u r e a u c r a t i c c o n t r o l of "development" Iharambee, s e l f - h e l p ) a c t i v i t i e s i n i t i a t e d by r u r a l - b a s e d , peasant communities. As a measure designed 22 to l i m i t the i n c r e a s i n g expenditure of scarce r e s o u r c e s , i t i s an a d m i n s t r a t i v e l y r a t i o n a l , r e s t o r a t i v e s t r a t e g y : i t presumes to c u r t a i l the r e p e t i t i o n of a l r e a d y planned " e s s e n t i a l s e r v i c e " programmes i n these areas (egs., health, c a r e , water, a g r i c u l t u r e , and e d u c a t i o n ) , and from the_ government's p o i n t of view, w i l l p u r p o r t e d l y d i m i n i s h the r i s i n g f r u s t r a t i o n of the average c i t i z e n Cwanansfri). i n v o l v e d i n hara.mb.ee p r o j e c t s . Holmguist summarizes the r a t i o n a l e of the government t h i s way: S e l f - h e l p was thought to be i n e f f i c i e n t and wasteful, l e a d i n g to poor grades of c o n s t r u c t i o n ; community c o m p e t i t i o n o f t e n l e d to a d u p l i c a t i o n of s e r v i c e s and chaos i n the c o n s t r u c t i o n process. S e l f - h e l p , i t was argued, a l s o encouraged p o l i t i c a l attempts t o i n f l u e n c e b u r e a u c r a t i c a l l o c a t i o n s , which only d i s r u p t e d budgeting processes and o p e r a t i n g procedures., S e l f - h e l p was a l s o , s a i d to be f r u s t r a t i n g the peasantry when outs i d e a s s i s t a n c e f a i l e d t o m a t e r i a l i z e or when the government r e f u s e d t o take over a p r o j e c t and meet r e c u r r e n t c o s t s . Such s i t u a t i o n s brought a f e e l i n g of d i s i l l u s i o n m e n t with the regime when i t was seen that l o c a l e f f o r t met with l i t t l e or no matching response from government and t h a t d i s p e n s a r i e s , f o r example, remained without medicine or p e r s o n n e l . 3 7 Nonetheless, i n s p i t e of t h i s c u r r e n t p o l i t i c a l and a d m i n i s t r a t i v e s i t u a t i o n ( ' p a r t i c i p a t i v e c e n t r a l i s m " ) , development p r o j e c t s c o n t i n u e to be fraught with t e n s i o n and i n t r i g u e . Leaders who are e l e c t e d and encouraged t o rep r e s e n t harambee p r o j e c t s are expacted t o persuade the government t o move i n c e r t a i n d i r e c t i o n s . T h i s s t r a t e g y — which Holmguist c a l l s "pre-emptive development" 3 8 — i s s t i l l an apparent p o l i t i c a l f o r c e between the r u r a l e l i t e s and the government: 23 The p o i n t i s not to choose something which you know i s a l r e a d y i n the government's pl a n but, r a t h e r more s u b t l y , t o f o r c e the government to go i n a d i r e c t i o n which, although not i n the p l a n , you know w i l l be d i f f i c u l t f o r i t t o r e s i s t . 3 9 1.3.2 The Current P o l i t i c a l , S o c i a l , and Economic S i t u a t i o n i n The R e p u b l i c of Kenya: Problems o f "Development" ~" "~ - - -The s t r a t e g y of "pre-emptive development" operates on the b a s i s of i d e a l i s t i c , and c u l t u r a l l y i l l - f o u n d e d assumptions. F i r s t of a l l , i t presumes t h a t the a d m i n i s t r a t i o n i s f l e x i b l e enough t o respond to i n d i v i d u a l r e q u e s t s f o r development [or harambee, s e l f - h e l p ) a s s i s t a n c e . U n f o r t u n a t e l y , the b u r e a u c r a t i c machinery i n the R e p u b l i c of Kenya — as i n most T h i r d World C o u n t r i e s — i s geared to a "top-down" s t r u c t u r e f o r planning, implementation, and a d m i n i s t r a t i o n of government programmes [see Chapter 2 f o r the case of the M i n i s t r y of H e a l t h ) . I t f u n c t i o n s as a f o r c e f o r domination and c o n t r o l r a t h e r than a body which i s capable of c r i t i c a l l y e v a l u a t i n g the m e r i t s of one development programme over another i n terms of r e l a t i v e need. As flienen suggests i n h i s r e i t e r a t i o n of c r i t i c s of Kenya's a d m i n i s t r a t i o n : . . . i t i s r e c r u i t e d and o r g a n i z e d f o r maintenance of order and c o n t r o l , not f o r i n n o v a t i o n or s t i m u l a t i o n of p a r t i c i p a t i o n from below. The h i g h l y c e n t r a l i z e d and b u r e a u c r a t i c nature of the C i v i l S e r v i c e ., . . m i l i t a t e s a g a i n s t i t s being a change-oriented i n s t i t u t i o n . * 0 Secondly, i t assumes that t h e r e i s democratic r e p r e s e n t a t i o n of t r i b a l and e t h n i c groups i n the c e n t r a l 24 government m i n i s t r i e s . In r e a l i t y , the government i s c u r r e n t l y (sic) c o n t r o l l e d by two very powerful Kikuyu t r i b a l f a c t i o n s ; 4 1 r e p r e s e n t e d by an " o l i g a r c h y of c a b i n e t m i n i s t e r s and top s t a t e bureaucrats t h a t has become i n c r e a s i n g l y i n d e p e n d e n t , " 4 2 these u p p e r - l e v e l managers are p o l i t i c a l a s p i r a n t s who compete with each other f o r f i n a n c i a l r e s o u r c e s t h a t w i l l b o l s t e r t h e i r own s t a t u s and v i s i b i l i t y i n t h e i r home c o n s t i t u e n c i e s . T h i s i s the m i n o r i t y o f i n d i v i d u a l s who immediately f o l l o w i n g Independence r a p i d l y gained c o n t r o l of s t r a t e g i c economic, s o c i a l , and p o l i t i c a l p o s i t i o n s . Bienen d e s c r i b e s the_ t r a n s i t i o n t h i s way: In a b s o l u t e and r e l a t i v e numbers more Kikuyu were upwardly mobile as they took over from Asian t r a d e r s , purchased l a n d from other t r i b e s e i t h e r alone or i n consortiums and c o o p e r a t i v e s , moved i n t o the former white farms, began t o move i n t o f o r e i g n commercial and i n d u s t r i a l e n t e r p r i s e s as managers, and i n c r e a s i n g l y moved i n t o the o f f i c e r corps. At the same time, Kikuyu were becoming l a n d l e s s and unemployed i n l a r g e numbers. 4 3 Whereas fo r m e r l y a s m a l l m i n o r i t y of Europeans c o n t r o l l e d f o u r - f i f t h s of the a g r i c u l t u r a l l y p r o d u c t i v e land ( i . e . i n t e a , c o f f e e , sugar cane, s i s a l , and wheat), t h i s l a n d was s w i f t l y a p p r o p r i a t e d by t h i s s m a l l m i n o r i t y of Kikuyu e l i t e s . 4 4 Permanently ensconced i n t h i s h i g h l y p r o d u c t i v e l a n d which surrounds the c a p i t a l c i t y of N a i r o b i , i t i s not at a l l s u r p r i s i n g t h a t a d i s p r o p o r t i o n a t e amount of government funds i s c u r r e n t l y b e i n g d i v e r t e d to t h i s area known as 25 Kikuyuland [ i . e . C e n t r a l P r o v i n c e ) . Furthermore, the money t h a t i s g e n e r a l l y given i s u s u a l l y a l l o c a t e d t o p u b l i c l y v i s i b l e , urban-based f a c i l i t i e s and i n s t i t u t i o n s . For example, i n t h e h e a l t h s e c t o r alone m i l l i o n s of Kenyan s h i l l i n g s have been spent on the Kenyatta N a t i o n a l H o s p i t a l i n N a i r o b i . Even though t h i s massive h e a l t h care i n s t i t u t i o n has been given poor marks as a c l i n i c a l l y d y s f u n c t i o n a l and badly designed f a c i l i t y , the message to the wananchi i s c l e a r : "development means the Development of Western images of w e l l - b e i n g ( i n modern s e r v i c e s , a m e n i t i e s , and s t a t u s e s ) r a t h e r than the promotion of comprehensive community "development" programmes i n v o l v i n g h e a l t h c a r e , water, e d u c a t i o n , a g r i c u l t u r e , and income-generating programmes i n urban as w e l l as i n r u r a l areas. Given the r e a l i t y of t h i s l e s s than e g u i t a b l e s o c i a l and economic s i t u a t i o n * i t i s c l e a r why p e r i p h e r a l groups (whether they be t r i b a l o r economically impoverished c l a s s e s ) are becoming i n c r e a s i n g l y d i s i l l u s i o n e d and bewildered. Groups l i k e the Luo — h i s t o r i c a l l y at odds with the K i k u y u * 5 — f e e l t h a t Uhuru (Independence/Freedom), and Harambee (Self-Help/Development) have brought them no f u r t h e r than the s t a t u s guo during c o l o n i a l r u l e . There i s s t i l l an apparent i n e g u a l i t y i n the o v e r a l l d i s t r i b u t i o n of economic r e s o u r c e s ; r a t h e r than a m i n o r i t y of Europeans i n c o n t r o l , an e l i t e m i n o r i t y of p o l i t i c a l l y and economically w e l l - h e e l e d i n d i v i d u a l s (mainly Kikuyu) dominate the 26 remaining t r i b a l and e t h n i c groups. While "Harambee" i s brandished as the symbol f o r an e t h i c a l , and j u s t l y c o n s t i t u t e d movement towards the "good s o c i e t y , " 4 6 i t f u n c t i o n s i n s t e a d as an i d e o l o g i c a l g l o s s which d i v e r t s a t t e n t i o n away from t h i s minority and the r e s o u r c e s i t c o n t r o l s . Those t r i b a l and ec o n o m i c a l l y thwarted m a j o r i t i e s that f i n d themselves on the pe r i p h e r y of these c e n t r e s of power, are f u l l y c o g n i z a n t of the a c t u a l machinations of the r u l i n g e l i t e , As a r e s u l t , t h e r e has been an e x a c e r b a t i o n of t r i b a l and r a c i a l t e n s i o n s entrenching r e g i o n a l i s m and p a r o c h i a l i s m , 4 7 a widening of the g u l f between the culture, of poverty and the c u l t u r e of p o l i t i c a l , economic, and t r i b a l e l i t e s , and subsequently, an a c c e n t u a t i o n of the d i s p a r i t i e s between r u r a l and urban government a s s i s t a n c e i n " e s s e n t i a l s e r v i c e s . " The world-wide economic r e c e s s i o n of the e a r l y 1980's has only i n t e n s i f i e d these d i f f i c u l t i e s . Those peasants who surge i n t o the major c i t i e s with hopes and dreams o f employment, o f t e n leave t h a t much poorer, or too embarrassed t o communicate t h e i r m i s f o r t u n e at home, f i n d themselves l i v i n g i n c i t y slums [eg. Hathare V a l l e y i n N a i r o b i ) . Students at the U n i v e r s i t y of N a i r o b i as well f e e l the i n j u s t i c e of the c u r r e n t s i t u a t i o n i n s p i t e of the f a c t t h at many of them are from prominent and powerful f a m i l i e s . And y e t , t h e i r p r o t e s t a t i o n s have onl y l e d to the c l o s u r e o f the U n i v e r s i t y , 4 8 and a c o n f i r m a t i o n of how 27 o p p r e s s i v e and r e p r e s s i v e the p o l i t i c a l s i t u a t i o n r e a l l y i s , * 9 To l i v e i n Kenya today i s t o experience the s e v e r i t y as w e l l as complexity of t h i s p o l i t i c a l , economic, s o c i a l , and c u l t u r a l s i t u a t i o n . The d i s p a r i t i e s i n wealth, a c r i p p l e d democracy with an i n c r e a s i n g l y c o r r u p t o l i g a r c h y , a fragmented s u b s i s t e n c e and market economy, a r e p r e s s i o n of freedoms of e x p r e s s i o n and communication, and a c r i t i c a l e v o l u t i o n of t r i b a l and e t h n i c t e n s i o n s . 1.3.3 Harambee, Development, and Communj.ty-Based H e a l t h Care: s i m i l a r Problems of Support, M e d i a t i o n , and Involvement In the context o f t h i s p o l i t i c a l l y - c h a r g e d and economically s t r i n g e n t s i t u a t i o n , harambee and/or s e l f - h e l p development i n the r u r a l areas has emerged as a d e f e n s i v e and r e a c t i v e s o c i a l movement.5<> I t i s a r e a c t i o n a g a i n s t the i n e f f e c t i v e bureaucracy o f the c e n t r a l government and a d e l i b e r a t e and o r g a n i z e d attempt t o get what i t can i n terms of f i n a n c i a l support, s u p p l i e s , and p r o f e s s i o n a l a s s i s t a n c e . C i t i n g G.C-M. Mutiso, Holmguist c l a i m s t h a t " s e l f h e l p i s a d e f e n s i v e s t r a t e g y of the periphery to squeeze what i t can out of a seemingly o p u l e n t and arrogant c e n t e r . " 5 1 Bather than development through c o o p e r a t i o n , the harambee movement i s s t r i d e n t l y r e a c t i o n a r y , a g g r e s s i v e , and cunning; i t i s a c o m p e t i t i v e game between government and community with only one party the winner. 28 To s u s t a i n the involvement and p a r t i c i p a t i o n of community members i n the harambee p r o j e c t r e q u i r e s a commitment and a l l e g i a n c e t o the g o a l s and o b j e c t i v e s of the p r o j e c t ; t h i s can only occur i f there i s a framework of shared e x p e r i e n c e , meanings, and b e l i e f s . Given the f a c t t h a t the haramb.ee community d e s i r e s to c r e a t e a more s a t i s f y i n g world and c u l t u r e , 5 2 M b i t h i c h a r a c t e r i z e s the s e l f - h e l p movement as a "focused s i t u a t i o n " and a "manufacturing ground f o r new value s and value s t a n d a r d s . " 5 3 M o b i l i z e d by respected and e l e c t e d community l e a d e r s — who a r e "married" t o the p r o j e c t f o r the d u r a t i o n of i t s development 5* -- t h e r e i s a d e l i b e r a t e and c o n s c i o u s d i a g n o s i s of community needs, an attempt to purge the movement of s e l f i s h and pe r s o n a l motives, and a g a t h e r i n g of people around common i n t e r e s t s and concerns. U s u a l l y t h e r e i s a common symbol which u n i f i e s the members i n the movement. I t may be a t r a d i t i o n a l c l a n or community symbol that i s r e v i t a l i z e d i n meaning f o r the d u r a t i o n of the p r o j e c t {a totem animal or name that d e r i v e s from an age-set, k i n s h i p , o r neighbourhood group — egs., a b u l l , l i o n , or snake), or an a c q u i r e d symbol that r e f l e c t s modern and Western standards o f wealth and e x c e l l e n c e [eg., a Mercedes-Benz)! Motivated by these, symbols, there i s i n c r e a s e d " s o l i d a r i t y " 5 5 between group members and a s t r e n g t h e n i n g and t i g h t e n i n g of group boundaries. 29 As mentioned, ; the harambee movement ( s e l f - h e l p development) — l i k e the s i t u a t i o n o f CBHC programmes t h a t are u n i l a t e r a l l y imposed — o f t e n ends i n f a i l u r e , f r u s t r a t i o n , and d e s p a i r . The p r o j e c t s do not always accomplish what they promised, and as a r e s u l t , the d i v i s i o n between the c e n t r e and the periphery i s i n c r e a s i n g l y widened.. R u r a l communities have developed an obvious s u s p i c i o n of government programmes — l i k e harambee — and have r e l i e d more i m p l i c i t l y on t r a d i t i o n a l o r g a n i z a t i o n s of support and c a r e . I n an i n t e r e s t i n g study c a r r i e d out by Miriam K. Were of the Department of Community H e a l t h , the U n i v e r s i t y of N a i r o b i , she found that even the Maendeleo ya Wanawake (the n a t i o n a l o r g a n i z a t i o n f o r women) i n s p i r e d l i t t l e c o nfidence i n the eyes of r u r a l , peasant women: I t was noteworthy t h a t these n a t i o n a l woman's o r g a n i z a t i o n s were not yet v i a b l e a t g r a s s r o o t s i n t h i s community. The groups t h a t d i d e x i s t (through which women a s s i s t e d one another with t a s k s such as weeding) were c h u r c h - r e l a t e d and/or neighbourhood g r o u p s . s 6 Harambee and Maendeleo ya Wanawake are p e r c e i v e d as government i n s p i r e d i n t e r v e n t i o n s . At a c e r t a i n l e v e l they i d e n t i f y s p e c i f i c f e l t - n e e d s i n r u r a l communities, but i n the process of a m e l i o r a t i o n , l i m i t the p o s s i b i l i t y f o r comprehensive development programmes ( f o r women, i n h e a l t h , i n water, etc.) and the dialogue and communication between groups (government and community) t h a t would i n s p i r e p a r t i c i p a t i o n and m o t i v a t i o n i n community members. For Harambee, Maendeleo ya Wanawake. and CBHC programmes 30 (whether government or non-government) a l i k e , t h i s i n t e r f a c e between (i) government/non-government o r g a n i z a t i o n s and ( i i ) community o r g a n i z a t i o n s generates the most s e r i o u s development problems: that i s , the d i f f i c u l t y i n c r e a t i n g and s u s t a i n i n g mutually s u p p o r t i v e systems of c a r e . And yet, i t i s through t h i s t e n s i o n that the most i n n o v a t i v e and e f f e c t i v e o r g a n i z a t i o n s of c a r e have emerged. 1.4 THgORETJCAL CONSIDERATIONS: THE ETHNOGRAPHIC SITUATION OF CBHC iBOGlAlHES IS KENYA I t i s i n t h i s c o n t e x t t h a t CBHC emerges as an a l t e r n a t i v e (though supplementary) h e a l t h care s t r a t e g y . , F o l l o w i n g on the heels of the Harambee movement and the c u r r e n t emphasis on a "broad based development" 5 7 e f f o r t i n r u r a l a r e a s , the, promise of CBHC (by the M i n i s t r y of Health) i s w a r i l y p e r c e i v e d as the l a t e s t i n a s e r i e s of " s e l f - h e l p " development programmes. Re p r e s e n t a t i v e l e a d e r s i n r u r a l communities are becoming wise to.the meaning of t h i s k i n d of " s e l f - h e l p development:" th e r e i s the experience of complete c o n t r o l o f the programme from above ( i . e . the c e n t r a l or d i s t r i c t government b o d i e s ) ; there i s g e n e r a l l y very l i t t l e d i s c u s s i o n between government r e p r e s e n t a t i v e s and the l e a d e r s of the " t a r g e t community" as to the nature and i m p l i c a t i o n s of the programme f o r them; and once the programme has been implemented (as i n Harambee p r o j e c t s ) , there i s no assurance t h a t the community can r e l y on the government i n f r a s t r u c t u r e f o r c o n t i n u i n g a l l o c a t i o n s of s u p p l i e s , f i n a n c i a l , and p r o f e s s i o n a l a s s i s t a n c e . 31 And yet, i n s p i t e of these apparent d i f f i c u l t i e s i n s o - c a l l e d " s e l f - h e l p development" (harambee) programmes, r u r a l communities w i l l s e i z e any opportunity made a v a i l a b l e to a m e l i o r a t e t h e i r p e r c e i v e d needs; i t i s a r i s k they take, and f o r them a r i s k worth t a k i n g . I f community-based health, care (CBHC) i s presented as the name f o r t h i s p o s s i b i l i t y , they w i l l respond to i t hoping t h a t t h e i r l e a d e r s w i l l be t h a t much wiser and adept at p r o t e c t i n g t h e i r i n t e r e s t s as a community. In the S a r a d i d i S u r a l Health Development P r o j e c t (see chapter 3) , f o r example, the p r o j e c t l e a d e r s have c o n s c i o u s l y and d e l i b e r a t e l y kept out p o l i t i c i a n s who would make of i t a p o l i t i c a l p l a t f o r m f o r t h e i r own i n d i v i d u a l advancement. This p r i n c i p l e to exclude the involvement of p o l i t i c a l a s p i r a n t s — agreed upon by the cadre o f community l e a d e r s — can be i n t e r p r e t e d as an i n d i r e c t , yet desperate attempt t o e x e r c i s e t h e i r p o l i t i c a l power. Furthermore, by doing t h i s , they a r e e x e r c i s i n g a form of s e l f - r e l i a n c e and s e l f - d e t e r m i n a t i o n t h a t i s t r u e t o the d e f i n i t i o n c o n s t r u c t e d f o r CBHC, and without ths knowledge [except f o r the P r o j e c t D i r e c t o r and a few others) of what t h i s s t r a t e g y f o r development has been conceived by i n t e r n a t i o n a l h e a l t h care o r g a n i z a t i o n s to mean. So too the Nangina Community Health Programme (see c h a p t e r 4 ) ; i n t h i s i n s t a n c e , the mis s i o n , h o s p i t a l , and clan-based communities have d i s c o v e r e d together an o r g a n i z a t i o n f o r c a r i n g and mutual support that only l a t e r have they come to r e a l i z e s u b s c r i b e s 32 to the n o t i o n of CBHC. CBHC i n t h i s s e t t i n g has evolved from a kind of 'growing to g e t h e r ' — a gr a d u a l merging of understandings o f what i t means to be, to be at one i n community, t o be healed, and to care f o r one another. A f t e r y e ars of "experimenting" with o t h e r , more dependent o r g a n i z a t i o n s of implementing d i s e a s e p r e v e n t i o n and h e a l t h promotion programmes, CBHC has emerged as the most v i a b l e , m u t u a l l y - s u p p o r t i v e h e a l t h care system between the c l a n communities and the h o s p i t a l - b a s e d s e r v i c e s . , The Ministry, of H ealth, on the o t h e r hand, has been l e s s m a l l e a b l e i n i t s a p p r e c i a t i o n of what CBHC means and i s . I n t e n t on developing even f u r t h e r i t s network of s t a t i c - b a s e d h e a l t h care f a c i l i t i e s , i t has responded to the c a l l f o r " h e a l t h f o r a l l by the year 2000" [through the v e h i c l e of CBHC) i n terms of a b i o m e d i c a l e p i s t e m i c system. H e a l t h care s e r v i c e s — a c c o r d i n g to t h i s c o n c e p t u a l framework — i s per c e i v e d as adequate and r e a d i l y a v a i l a b l e c l i n i c a l s e r v i c e s p r o v i d i n g drugs and the c u r a t i v e p o t e n t i a l of d o c t o r s and nurses. CBHC, t h e r e f o r e , i s merely appended onto t h i s a l r e a d y planned and g r a d u a l l y implemented programme of p r o v i d i n g c l i n i c a l f a c i l i t i e s [from h o s p i t a l s , , r u r a l h e a l t h t r a i n i n g c e n t r e s , h e a l t h s u b - c e n t r e s , to d i s p e n s a r i e s ) . Prodded on by a i d o r g a n i z a t i o n s who promise to fund h e a l t h care programmes with a c e n t r a l CBHC f o c u s , the M i n i s t r y of Health has complied -- yet onl y on paper -— and i s embarking on p i l o t programmes i n CBHC t h a t are 33 planned, implemented, and supposedly managed from headguarters i n N a i r o b i (see chapter 2) . I t w i l l be evident i n the ethnographic cases presented {chapters 2-4) that "community-based h e a l t h c a r e " (CBHC) as a g l o s s f o r a c h i e v i n g comprehensive f a m i l y p l a n n i n g , d i s e a s e p r e v e n t i o n , and h e a l t h promotion programmes — must be r e l a t e d t o these s i t u a t i o n a l l y - d e r i v e d v a l u e s , b e l i e f s , and understandings. Furthermore, i n e x p l i c a t i n g the process through which CBHC programmes a r e s o c i a l l y n e g o t i a t e d and (hopefully) accomplished i n r u r a l communities, i t i s necessary to not only i n t e r p r e t the c u l t u r e and epistemology of h e a l t h care knowledge o f the community i n which CBHC i s t a k i n g r o o t , but the c u l t u r e of the s u p p o r t i n g h e a l t h care i n f r a s t r u c t u r e as w e l l — whether provided by government, mis s i o n , or non-government (eg. research) o r g a n i z a t i o n s . In most i n s t a n c e s , these two c u l t u r a l systems are never complementary, but r a t h e r , embroiled i n r e l a t i o n s h i p s of e i t h e r s u p e r o r d i n a t i o n / s u b o r d i n a t i o n , c o m p e t i t i o n / c o o p e r a t i o n , or o p p o s i t i o n . In s h o r t , t h e r e i s a d i a l e c t i c evidenced i n CBHC s i t u a t i o n s t h a t engages d i f f e r i n g spheres of a u t h o r i t y , power, and w e l l - b e i n g . , a fundamental i s s u e i n the mediation of these d i f f e r e n c e s i s the experience of i n d i v i d u a l s [and c o l l e c t i v i t i e s of i n d i v i d u a l s ) who s t r u g g l e t o work themselves c l e a r of these impinging c u l t u r a l c o n s t r a i n t s — t h a t of the system which imposes or i n t e r v e n e s with a model f o r CBHC, and t h a t of the 34 r u r a l - b a s e d community which has s e l e c t e d them to r e p r e s e n t them i n the programme. As was mentioned, the Community H e a l t h Workers (CHWs) — together with the support system of liilaae Health Committees (VHCs), P r o j e c t D i r e c t o r s , and CHW n u r s e - t r a i n e r s — r e f r a c t i n t h e i r person and p o s i t i o n these impinging e p i s t e m i c systems. C o n s t r a i n e d by the impact of these c u l t u r a l systems which r e p r e s e n t d i f f e r e n t requirements f o r a l l e g i a n c e and a c c o u n t a b i l i t y , these CHWs are compelled to s i t u a t e themselves i n terms of moral and e p i s t e m o l o g i c a l r e l e v a n c e s which f o r them are deemed worthwhile. Worthwhileness i s a word which c o n t a i n s f o r the i n d i v i d u a l a l l the elements of t h i s d i a l e c t i c . I t i s an e v a l u a t i o n of one's e x p e r i e n c e s and r e l a t i o n s h i p s with s e l f and with o t h e r s , and i n the i n s t a n c e of a CBHC programme, may be p r e d i c a t e d on i s s u e s of b e l i e f money, t r a d i t i o n a l v a l u e s , and/or p e r c e p t i o n s of work. In the t h r e e ethnographic cases presented, worthwhileness f o r the Community Health Worker (CHW) gathers together a number of d i s t i n c t p r o c e s s e s : the CHW i n the M i n i s t r y of H e a l t h P i l o t p r o j e c t f o r CBHC i s motivated f o r reasons of p r o f e s s i o n a l advancement through the h e a l t h c a r e system; the CHW i n the S a r a d i d i R u r a l H e a l t h Development P r o j e c t i s i n s p i r e d by h i s / h e r t r a d i t i o n a l c o u n t e r p a r t -— the nyamrerua — and i s * i n most ca s e s , honoured and respected f o r t h e i r work and c o n t r i b u t i o n i n the community; and l a s t l y , the CHW i n t h % Nangina Community H e a l t h Programme i s encouraged, 35 strengthened, and drawn to t h e i r work by o t h e r persons i n t h e i r C h r i s t i a n Community Groups (CCGs) and by each o t h e r . 1.4.1 Complex, S u b s i s t e n c e , and Peasant S o c i a l O r g a n i z a t i o n s : The S i t u a t i o n o f Impinging S o c i a l -C u l t u r a l R e a l i t i e s i n CBHC ~ ~ ~ In a s e r i e s of t h e o r e t i c a l p u b l i c a t i o n s i n anthropology, Kenelm B u r r i d g e 5 8 e x p l o r e s the bo r d e r l a n d between opposing c u l t u r a l systems i n a s u c c e s s f u l attempt to c o n c e p t u a l i z e and e x p l a i n the g e n e r a t i o n of s o c i a l ^ c u l t u r a l movements. The s i g n i f i c a n c e of h i s t h e o r e t i c a l c o n t r i b u t i o n t o an understanding of CBHC programmes i s r e p l e t e . . S e p a r a t i n g the methodological and t h e o r e t i c a l elements of h i s explanatory framework i n t o h i s views on r e l a t i o n a l a n a l y s i s , ethnographic e x p l a n a t i o n ( s t r u c t u r a l and phenomenological) , and i n d i v i d u a l i t y , I w i l l address each p e r s p e c t i v e i n tu r n as i t e l u c i d a t e s the a n t h r o p o l o g i c a l problem of t h i s t h e s i s . I t i s ev i d e n t t h a t each s i t u a t i o n of CBHC b r i n g s together d i f f e r i n g and sometimes d i s p a r a t e c u l t u r a l systems. More s p e c i f i c a l l y , s i n c e CBHC programmes are designed f o r r u r a l , more p e r i p h e r a l areas i n the country, and while the agent of change u s u a l l y r e p r e s e n t s a modern and s c i e n t i f i c a l l y 5 9 o r i e n t e d c u l t u r e , i t i s u s e f u l t o thin k of CBHC events as emerging out of the c o n f l u e n c e of complex, s u b s i s t e n c e and/or peasant s o c i a l o r g a n i z a t i o n s . In terms of v a l u e s , economies, and moral requirements, these c o n f i g u r a t i o n s of s o c i a l o r g a n i z a t i o n a r e c l e a r l y s eparate i n t h e i r symbolic 36 and, e p i s t e m o l o g i c a l c o n s t r u c t i o n . Indeed, except f o r peasant s o c i a l o r g a n i z a t i o n , the s o c i a l r e l a t i o n s t h at c h a r a c t e r i z e s u b s i s t e n c e and complex o r g a n i z a t i o n s are cons i d e r e d t o be mutually e x c l u s i v e . 6 0 B u r r i d g e d e f i n e s S u b s i s t e n c e economies as a combination of b a s i c elements and r e l a t i o n s t h a t f l e s h out a whole c u l t u r e : a l l persons i n the community take p a r t i n s u b s i s t e n c e a c t i v i t i e s , and the s t a t u s and p r e s t i g e t h a t a c c r u e s t o persons i n the community i s granted on the b a s i s of age, sex, and success i n accomplishing these elementary endeavours, and i n a d d i t i o n , the a b i l i t y to share the f r u i t s o f t h i s work with r e l a t i v e s , neighbours, and f r i e n d s . 6 1 While s p e c i a l i s t s a re d e f e r r e d t o on c r i t i c a l o c c a s i o n s to pr o v i d e a c e r t a i n s e r v i c e [ in t h e i r c a p a c i t y as d i v i n e r s , magicians, and h e a l e r s ) , t h e i r f u n c t i o n i n t h i s c a p a c i t y i s temporary, only l a t e r t o be subsumed by the day t o day a c t i v i t i e s and n e c e s s i t i e s of the s u b s i s t e n c e economy. As such, r e l a t i o n s between persons a r e continuous and ongoing: A g i v e s t o B, B r e t u r n s to A, A again g i v e s t o B [A=_~ B) . The p r o c e s s i s completed e i t h e r when both p a r t i e s e xpress themselves s a t i s f i e d , or when one becomes the permanent debtor of the oth e r and so the l a t t e r * s r e t a i n e r . B a s i c a l l y and i n p r i n c i p l e the moral determinant of S u b s i s t e n c e economy i s the e q u i v a l e n c e of g i v i n g and r e c e i v i n g [giving =0= r e c e i v i n g ) . 6 2 While i n Subsi s t e n c e economies there i s a conti n u o u s and c y c l i c a l r e p e t i t i o n of these a c t i v i t i e s and r e l a t i o n s with each g e n e r a t i o n . Complex economies are stopped s h o r t through the i n t r o d u c t i o n of money. 6 3 Honey promotes the c o n s e r v a t i o n 37, and accumulation of wealth and r e s o u r c e s — u n l i k e the temporal and v u l n e r a b l e s t a t e of •t h i n g s of v a l u e 1 i n s u b s i s t e n c e economies and encourages the s e p a r a t i o n of i n d i v i d u a l i n t e r e s t s and r e l a t i o n s h i p s ( i . e . n o n - r e c i p r o c a l ) from that of the l a r g e r community of persons: Health, i n money, can accumulate and command l a b o r , s e r v i c e s , and goods not a v a i l a b l e i n a Subsistence economy. Whereas i n a S u b s i s t e n c e economy exchanges are c o n t i n u i n g [A« ^ B) , p r e s c r i p t i v e , and w i t h i n the k i n or f r i e n d s h i p idioms, thus e n f o r c i n g narrow and t r a d i t i o n a l m o r a l i t i e s , t r a n s a c t i o n s with money may cut the r e l a t i o n s h i p with a s i n g l e do ut des [A^=tB), make f r e e markets p o s s i b l e , open r e l a t i o n s h i p s t o choice and p r e f e r e n c e , c o n v e r t the m o r a l i t i e s i n t o a l l o w a b l e o p t i o n s . 6 4 With money, t h e r e f o r e , a person i s r e l e a s e d from t r a d i t i o n a l p a t t e r n s of o b l i g a t i o n and a c c o u n t a b i l i t y . The o p p o r t u n i t y i s s t i l l t h e r e t o submit t o t r a d i t i o n a l a u t h o r i t i e s , or a l t e r n a t i v e l y , f e e l i n g c o n f i d e n t t h a t one can make i t al o n e , a person can develop r e l a t i o n s h i p s t h a t are s e l f - s e r v i n g and s e l f - e n h a n c i n g . f o r Community H e a l t h Workers (CHWs) i n CBHC programmes,. money — i n the form of a s a l a r y or remuneration f o r s e r v i c e -- i s con s i d e r e d the key t o t h e i r advancement as h e a l t h care p r o f e s s i o n a l s and t h e r e f o r e s o c i a l l y s u c c e s s f u l , modern i n d i v i d u a l s . ^ On o c c a s i o n , however, the CHWs choose [or are compelled) to become vo l u n t e e r s i n the CBHC programme; n e v e r t h e l e s s , t h e r e g e n e r a l l y appears from some quarter (husband or r e l a t i v e ) the s o c i a l pressure t o work only f o r money. In t h i s s i t u a t i o n , they can e i t h e r submit to t r a d i t i o n a l or modern pres s u r e s o r, s e i z e d by some other 38 awareness or s e t of r a t i o n a l i z a t i o n s , c r e a t e more compelling s i t u a t i o n s o f r e l e v a n c e . As Burridge suggests: . . the c r i t i c a l s i t u a t i o n i s where the t e n s i o n s between giving, =C= r e c e i v i n g and g i v i n g r e c e i v i n g occur w i t h i n the same aggregation. For i n t h i s s i t u a t i o n , informed as i t a l s o i s with c o n t r a s t s i n the v a r i e t y of r o l e s and i d e n t i t i e s to be encountered w i t h i n approximately the same i n t e r a c t i o n a l range, the person i s c o n t i n u a l l y presented with o p p o r t u n i t i e s f o r moral c h o i c e , c r i t i q u e , and i n n o v a t i o n . 6 5 T h i s dilemma of e q u i v a l e n t economies ( r e c i p r o c a l ) i n t e n s i o n with n o n - e q u i v a l e n t economies ( n o n - r e c i p r o c a l ) i s the fundamental exper i e n c e i n Peasant c o m m u n i t i e s . 6 6 There i s always a ch o i c e to be made. For the CHWs i n t h i s study, worthwhileness hinges on adherence t o e i t h e r one s e t of moral p r i n c i p l e s or another. And yet, p e r c e i v i n g CBHC as an event t h a t c r e a t e s o t h e r p o s s i b i l i t i e s f o r l i f e i n the community, the o p p o r t u n i t y f o r a l t e r n a t i v e d i r e c t i o n s and avenues of change p r e s e n t s i t s e l f — f o r those who are i n a p o s i t i o n to hear — through r e v e l a t i o n s , c o n v e r s i o n s , and dreams. 1.4.2 R e l a t i o n s h i p s , S t r u c t u r e s , and Events i n Ethnographic E x p l a n a t i o n The person who ex p e r i e n c e s the o p p o s i t i o n s , t e n s i o n s , and a m b i g u i t i e s i n h e r e n t i n the peasant s i t u a t i o n i s t o r n between c o n f l i c t i n g systems of moral r e l e v a n c e s . On the one hand, there a re the o b l i g a t i o n s and r e s p o n s i b i l i t i e s t h a t f o l l o w r e l a t i o n s of k i n s h i p ; there are f e a s t s t o a t t e n d , payments to be made towards s a c r i f i c e s , b r i d e w e a l t h s , and 39 f u n e r a l s , and a host of other expenditures t h a t would t e s t the most vigorous of e n t r e p r e n e u r i a l s p i r i t s — f o r example harambee c o n t r i b u t i o n s and s c h o o l t u i t i o n s and f e e s . On the o t h e r hand, i f a man works i n the town and i s drawn even f u r t h e r i n t o the network of v i l l a g e and community o b l i g a t i o n s — because of h i s r e l a t i v e p o s i t i o n of p r e s t i g e and wealth as one of the few s a l a r i e d workers i n the community — and i s bound t o q u e s t i o n h i s a l l e g i a n c e t o t r a d i t i o n a l systems of a c c o u n t a b i l i t y . With time, he may be f o r c e d to choose one system of s o c i a l r e l a t i o n s over another; o r , as i s o f t e n the case, he may n e g o t i a t e a d i f f i c u l t and p r e c a r i o u s balance between both systems. Whatever the p o s i t i o n , the person i n s o c i e t y i s compelled t o c o n t i n u o u s l y d i s c h a r g e debts of o b l i g a t i o n . In r e l a t i o n to the more powerful, n o n - r e c i p r o c a l o t h e r 6 7 — whether a parent, a n c e s t o r , g u a r d i a n , s p i r i t , d e i t y , or the moral i m p e r a t i v e s of the community i t s e l f 6 8 — the person i s compelled to redeem him or h e r s e l f of the debts they f e e l they owe. In complex economies, i t i s p o s s i b l e t o i n s u l a t e o n e s e l f from an ever-expanding s e r i e s of debts, r e s p o n s i b i l i t i e s , and o b l i g a t i o n s ; s o c i a l r e l a t i o n s can be rendered non-equivalent by a simple payment o f money f o r a s e r v i c e , a work, o r a commodity. Yet i n s u b s i s t e n c e economies, an awareness of s e l f i s r e f r a c t e d through a l l p a r t s of the moral system: r e l a t i o n s to c l a n members, p a r t i c i p a t i o n i n s u b s i s t e n c e a c t i v i t i e s , a w i l l i n g n e s s to 40 p r o f f e r a v a l u a b l e s e r v i c e , and an adherence to the c e n t r a l p r i n c i p l e s of the community l i f e a l l c o n t r i b u t e to the measure of the man or woman. As our case s t u d i e s suggest, persons i n peasant s i t u a t i o n s are c o n s t r a i n e d by c o n f l i c t i n g moral systems, sources of t r u t h , and r e l a t i o n s of power. There a r e , f o r example, the competing requirements of t r a d i t i o n a l and b u r e a u c r a t i c o b l i g a t i o n s , the message of the mission a g a i n s t the wisdom of the e l d e r s , and the a t t r a c t i o n of s a l a r i e d work i n r e l a t i o n to clan-abased o r g a n i z a t i o n s of support and c a r e . In the f a c e of these c o n t i n g e n c i e s , the problem i s one of d i s c r i m i n a t i o n ; how i t i s p o s s i b l e t o know and to ; determine which d i r e c t i o n s and p o s s i b i l i t i e s are t r u e . Burridge r e f e r s t o t h i s process as c h a r a c t e r i s t i c a l l y r e l i g i o u s ; The redemptive process i n d i c a t e d by the a c t i v i t i e s , moral r u l e s , and assumptions about power which, p e r t i n e n t to the moral order and taken on f a i t h , not only enable a people t o p e r c e i v e the t r u t h of t h i n g s , but guarantee t h a t they are indeed p e r c e i v i n g the t r u t h of t h i n g s . 6 9 The Community H e a l t h Workers {CHWs), and o t h e r s l i k e them i n the community, exemplify t h i s process of responding to p a r t i c u l a r assumptions of power. Whereas they f i n d themselves "betwixt and between" c o n f l i c t i n g r e l a t i o n s of power — i . e . . the d u a l requirements of s u b s i s t e n c e and complex economies, r e c i p r o c a l and n o n - r e c i p r o c a l r e l a t i o n s h i p s , p a r t - t i m e and f u l l - t i m e work, cl a n - b a s e d and b u r e a u c r a t i c e x p e c t a t i o n s , and s p i r i t u a l and p r o f e s s i o n a l 41 g o a l s 7 0 — they have responded t o CBHC as an event that r e l e a s e s them of these apparent t e n s i o n s and causes them t o transcend these d i f f i c u l t i e s i n a r e s p e c t a b l e and a worthwhile manner. There a re d i f f e r i n g e x p e r i e n c e s a s s o c i a t e d with the r a t i o n a l i z a t i o n of worthwhileness, but even so, i t c o n t a i n s i n one word the d i s c e r n i b l e m a n i f e s t a t i o n s of the t r u t h and the p e r c e p t i o n of r e a l i t y t h a t they have come t o a p p r e c i a t e . The CHWs i n the S a r a d i d i B u r a l Health Development P r o j e c t c o n s i d e r t h e i r work and p o s i t i o n as a r e v i t a l i z e d a p p r e c i a t i o n of the nyamrerua or t r a d i t i o n a l h e a l e r ; the CHWs i n the Nangina Community Health Programme l e g i t i m a t e t h e i r work as a m a n i f e s t a t i o n of t h e i r s p i r i t u a l " g i f t s " and t h e i r necessary place i n C h r i s t i a n community; while the CHWs i n the M i n i s t r y of H e a l t h p i l o t programme c o n s i d e r t h e i r p o s i t i o n as an e x p r e s s i o n of p r o f e s s i o n a l and medical worthwhileness. The phenomenology of each of these separate c o n s t r u c t i o n s of worthwhileness, s i t u a t e d as they are i n terms of d i f f e r i n g s o c i a l r e l a t i o n s and e p i s t e m o l o g i e s of power and of t r u t h , i s the r e l a t i o n s h i p t h a t I w i l l seek to prov i d e as the ethno g r a p h i c e x p l a n a t i o n of t h i s t h e s i s . as Burr i d g e e x p l a i n s , the a n t h r o p o l o g i c a l endeavour must i n d i c a t e : . the r e l a t i o n s h i p between what a c t u a l l y happens t o people, e v e n t s , and the forms and modes by which those events are a r t i c u l a t e d and made communicable by r a t i o n a l i z a t i o n s , i n t e l i e c t u a l i z a t i o n s , and symbolic r e p r e s e n t a t i o n s . 7 1 42 1.4.3 Person, I n d i v i d u a l , and I n d i v i d u a l i t y S p e c i a l persons ( i . e . i n d i v i d u a l s ) are needed t o accomplish the necessary mediation and n e g o t i a t i o n s of sepa r a t e worlds. In most i n s t a n c e s , persons do not have the v i s i o n , i m a g i n a t i o n , or cunning f o r what i t takes to s e i z e the events as they are presented, and i n so doing, r e l a t e the t r u t h as they e x p e r i e n c e i t to the r e a l i t y s e t before them. They succumb i n s t e a d t o the c a t e g o r i e s , r o l e s , and t i t l e s of s t a t u s and rank. I n d i v i d u a l s , on the other hand, are capable of t r a n s c e n d i n g a v a i l a b l e moral o r d e r s because of what they have seen and come to b e l i e v e (.a metanoia) , and concomitantly, r e l a t e d i n t h i s message to s o c i a l - c u l t u r a l r e a l i t i e s . U n l i k e o t h e r men and women who are content with b e i n g persons, the i n d i v i d u a l i s compelled t o c r i t i c i z e , r e v i t a l i z e , and change e x i s t i n g moral o r d e r s . 7 2 But then f o r i n d i v i d u a l s , t h e r e are moments when they are persons as w e l l : Yet i f some people are wholly i n d i v i d u a l s and others a r e persons, i t i s a matter of common ob s e r v a t i o n t h a t most people are i n some r e s p e c t s and most f r e q u e n t l y persons while i n other r e s p e c t s and a t o t h e r times they can appear as i n d i v i d u a l s . And t h i s apparent o s c i l l a t i o n or movement between person and i n d i v i d u a l — whether i n a p a r t i c u l a r i n s t a n c e the movement i s one way or a r e t u r n i s made — may be i d e n t i f i e d as i n d i v i d u a l i t y . 7 3 T h i s process can be i n d i c a t e d t h i s way: 7 4 43 I n Someone, No One; An Essay on lQ.diyidualt__, Kenelm Bu r r i d g e s u c c e s s f u l l y e l u c i d a t e s the moments of t h i s process between person and i n d i v i d u a l . He examines the l i f e - w o r l d of prophets, m y s t i c s , and c h a r i s m a t i c l e a d e r s , and i n d i c a t e s how i t i s that they are a b l e t o move people i n c e r t a i n d i r e c t i o n s of change. I t i s because they a r e a b l e to a r t i c u l a t e s p e c i f i c i n t e g r a t i o n s of b e l i e f and experi e n c e — r e l a t i n g s p i r i t u a l t r u t h s (from dreams, myths, and myth-dreams) 7 5 to a v a i l a b l e m o r a l i t i e s — t h a t they c e r t i f y these perceived t r u t h s and transcend the d i s c r e p a n c i e s of opposing worlds and m o r a l i t i e s . Burridge i d e n t i f i e s the elements of t h i s c r i t i c a l and r e f l e c t i v e p rocess t h i s way: ( s e l f / o t h e r s ) + [ s e l f / m o r a l i t i e s ) + ( s e l f / t r u t h ) — > i n d i v i d u a l 7 6 B u r r i d g e 1 s t h e s i s on the i n d i v i d u a l p r o v i d e s an a p p r o p r i a t e and cogent framework f o r e x p l a i n i n g the work of the Community He a l t h Worker (CHW) i n CBHC programmes. CBHC programmes have emerged as e v e n t u a l i t i e s t h a t can e i t h e r be avoided ( l i k e Harambee programmes that a re l i n k e d to government c o n t r o l s and a d m i n i s t r a t i o n ) , or i n t e r p r e t e d as promising domains of development and growth. N e v e r t h e l e s s f o r programmes of t h i s s o r t to remain v i a b l e , i n n o v a t i v e , and s u s t a i n e d by community members and h e a l t h care i n f r a s t r u c t u r e s a l i k e , the impe r a t i v e i s there f o r programmes to be c o n s t r u c t e d through d i a l o g u e , communication, and encounter between r e p r e s e n t a t i v e s of the h e a l t h c a r e i n f r a s t r u c t u r e , and l e a d e r s i n the community 44 i t s e l f . U n f o r t u n a t e l y , development programmes (whether dubbed harambee, "from below," "broad-based," or "community-based") u s u a l l y r e s u l t i n some p a t t e r n of do m i n a t i o n / s u b o r d i n a t i o n , o p p o s i t i o n / c o o p e r a t i o n , and i n f r e q u e n t l y i n an e f f e c t i v e programme of complementarity of s e r v i c e s , work, and agreements. i s such i t i s u s u a l l y the system t h a t i n t e r v e n e s with some model f o r development t h a t imposes i t s w i l l and purposes on the members of " r e c i p i e n t " and " t a r g e t " communities. C o n s t r a i n e d by these apparent o p p o s i t i o n s and dilemmas, t h e r e i s always the o p p o r t u n i t y f o r c h a r i s m a t i c i n d i v i d u a l s and l e a d e r s [ r e l i g i o u s l e a d e r s , prophets, and guardians) to c r e a t e a u t h e n t i c s o c i a l o r d e r s i n s p i t e of these impinging and t h r e a t e n i n g r e a l i t i e s . In the CBHC programmes t h a t are now to be d e s c r i b e d ( e s p e c i a l l y cases 2 and 3 ) , the Community H e a l t h Workers (CHWs) have, t o some e x t e n t , n e g o t i a t e d these c o n f l i c t i n g moral u n i v e r s e s and r e l a t e d t h e i r work as CHWs to tr a n s c e n d i n g , and d e l i b e r a t e l y c r e a t i n g axioms of t r u t h and power, These CHWs are i n d i v i d u a l s who, d i s s a t i s f i e d with o r d i n a r y and p r e d i c t a b l e r e a l i t i e s , have s e i z e d every opportunity to c r e a t e new and a u t h e n t i c s i t u a t i o n s f o r l i v i n g , r e l a t i n g , and working i n the community. 45 ENDNOTES In Gender (New York: Pantheon Books, 1982},. esp. pp. 5-6, Ivan I l l i c h b u i l d s on the study of 'key words* p o s i t e d by Raymond W i l l i a m s , Key-Words; 4 Vocabulary, of C u l t u r e and S o c i e t y (Sew York: Oxford U n i v e r s i t y Press, 1976). 'Community-based h e a l t h c a r e ' (CBHC) i s a key word i n the sense t h a t i t i d e n t i f i e s and imputes a s p e c i f i c c o n s t e l l a t i o n of needs i n community l i f e . For comparison, ' t r a n s p o r t a t i o n , ' 'medicine,* 'education,* 'development,' and 'consumer* are c o n s i d e r e d t o be key words. Kenelm Burridge examines the moments of the i n d i v i d u a l and the person, and the movements between them, i n Someone, No One: An Essay on I n d i v i d u a l i t y ( P r i n c e t o n , New J e r s e y : P r i n c e t o n U n i v e r s i t y P r e s s , 1979). The r e l e v a n c e o f t h i s t h e o r e t i c a l c o n t r i b u t i o n to t h i s study i s t r e a t e d more f u l l y below. UNICEF/WHO J o i n t Committee on Health P o l i c y , N a t i o n a l Decision-making f o r Primary Health Care (Geneva: World Health O r g a n i z a t i o n , 1981), p. 47. Using examples from the Sudan, the U n i t e d R e p u b l i c of Tanzania, the Republic of Ghana, I n d i a and S.E. A s i a , F.J.; Bennett reviews the d i v e r s e s t r a t e g i e s employed i n the implementation of PHC programmes i n "Primary Health Care and Developing C o u n t r i e s , " S o c i a l Science and Medicine, 13A (1979), pp. 505-514. A. Benyoussef reviews the, s i t u a t i o n of CBHC programmes — or what he c a l l s " b a s i c " h e a l t h c a r e — i n C h i n a , Tanzania, Venezuala, I n d i a , Cuba,, Niger, and I r a n , i n " H e a l t h Care i n Developing C o u n t r i e s , " S o c i a l S c i ence and Medicine, 11 ( 1 9 7 7 ) , pp.,399-408. More s p e c i f i c a l l y , V i c t o r W» S i d e l and Ruth S i d e l examine the r e l a t i o n s h i p between PHC programmes and the s o c i o - p o l i t i c a l s t r u c t u r e as a p p l i e d to Sweden, B r i t a i n , , the S o v i e t Union, the U.S.A., China, and C h i l e , i n "Primary Health Care i n R e l a t i o n to S o c i o - P o l i t i c a l S t r u c t u r e , " S o c i a l S c i e n c e and Medicine, 11 (1977), pp. 415-419. For a v e r y b r i e f overview of the r e l a t i v e d i f f e r e n c e s i n PHC programmes, see as w e l l the World Health - O r g a n i z a t i o n , "Primary Health Care i n the WHO Regions," WHO C h r o n i c l e , 32 (1978), pp. 431-438. D i r e c t o r - G e n e r a l of the World Health O r g a n i z a t i o n and the Executive D i r e c t o r of the United Nations I n t e r n a t i o n a l C h i l d r e n ' s Emergency Fund, Primary Health Care: Report of the I n t e r n a t i o n a l Conference on Primary Health Care (Geneva and New York: World Health O r g a n i z a t i o n , 1978), pp. 2-3. Quoted from the WHO/UNICEF "Report of the I n t e r n a t i o n a l Conferences on Primary H e a l t h Care" (ICPHC/ALA/78.10.), i n 46 F . J . Bennett, "Primary Health Care i n Developing C o u n t r i e s , " S o c i a l S c i e n c e and Medicine, 13A (1979), p. 505. 6 World Health O r g a n i z a t i o n , "The Alma-Ata Conference on Primary Health Care," WHO C h r o n i c l e , 32 (1978), pp. 409-430.. 7 C f . , UNICEF/Who J o i n t Committee on H e a l t h P o l i c y , Matioaal, Decision-making f o r Primary Health Care (Geneva: World Health O r g a n i z a t i o n , T98177 8 T h i s was the d e c i s i o n of the f o u r t e e n t h p l e n a r y meeting of the World Health O r g a n i z a t i o n , 19 May 1977, and guoted i n : World Health O r g a n i z a t i o n , "The Alma-Ata Conference on Primary Health Care," WHO C h r o n i c l e , 32 (1978), p. 429. 9 World Health O r g a n i z a t i o n , B a s i c Documents, 26th ed. (Geneva: World Health O r g a n i z a t i o n , 1976), p. 1. 1 0 World Health O r g a n i z a t i o n , "The Alma-Ata Conference on Primary Health Care," WHO C h r o n i c l e , 32 (1978), pp. 428-429.. 1 1 I b i d . ; c f . as w e l l : Aga Khan Foundation and World Health O r g a n i z a t i o n , The Role of H o s p i t a l s i n Primary Healthj Care (Geneva: Aga Khan Foundation and World Health O r g a n i z a t i o n , 1981).. World Health O r g a n i z a t i o n , "The Alma-Ata Conference on Primary H e a l t h c a r e , " WHO C h r o n i c l e , 32 (1978), pp.-428-429. 1 3 World Health O r g a n i z a t i o n , "The Alma-Ata Conference on Primary Health Care," WHO. C h r o n i c l e , 32 (1978). i * 0NICEF/WHO J o i n t Committee on Health P o l i c y , National; Decision-making f o r Primary Health Ca^re (Geneva: World Health O r g a n i z a t i o n , 1981), p. 48. * s R.B. I s e l y , " R e f l e c t i o n s on an Experience i n Community P a r t i c i p a t i o n i n Cameroon," Annales de 1| Soc.ie.te bel,g§ de Medecine t r o p i c a l e , 59 (1979), Suppl., p. 112. See as w e l l : Raymond B. I s l e y and Jean F. M a r t i n , "The V i l l a g e Health Committee: S t a r t i n g P o i n t f o r B u r a l Development," WHO C h r o n i c l e , 31 (1977), pp. 307-315; and Raymond B. I s l e y , L a r d j a L. Sanwogol, and Jean F. M a r t i n , "Community O r g a n i z a t i o n as an Approach t o Health Education i n R u r a l A f r i c a , " I n t e r n a t i o n a l J o u r n a l of. Health E d u c a t i o n , Supplement to XXII, Issue No., 3 7July-September"1979), pp. 1-19. 0NICEF/WH0 I n t e r r e g i o n a l Study and Workshop, Primary 47 Health Care: The Community Health Care Worker (Kingston, Jamaica: World H e a l t h O r g a n i z a t i o n and United Nations I n t e r n a t i o n a l C h i l d r e n ' s Emergency fund, 1979/1980), p.. 9. * 7 D. B a n e r j i , "The Sol e of H o s p i t a l s i n Promoting and Using Community P a r t i c i p a t i o n i n the Development of Primary Health Care," In Aga Khan Foundation and World Health O r g a n i z a t i o n , The S o l e of H o s p i t a l s j_n. P£iaar.y_ Health. £a££ (Geneva: Aga Khan Foundation and World Health O r g a n i z a t i o n , 1981) , p. 34. 1 8 D a n i e l F l a h a u l t , "The R e l a t i o n s h i p Between Community Hea l t h Workers, the Hea l t h S e r v i c e s , and the Community," WHO C h r o n i c l e . 32 (1978), p. 150.. 1 9 John II. Bryant, "Community Health Workers: The I n t e r f a c e Between Communities and Health Care Systems," WHQ C h r o n i c l e , 32 (1978), p. 145. 2 0 f o r an e x p l a n a t i o n of t h i s u s e f u l n o t i o n i n the l i t e r a t u r e of medical anthropology, see: Arthur Kleinman, "Family-Based Popular Health C u l t u r e , " In P a t i e n t s and Healers i n the Context of C u l t u r e : An E x p l o r a t i o n of the Bor d e r l a n d Between Anthropology, Medicine, and P s y c h i a t r y (Berkeley: the U n i v e r s i t y of C a l i f o r n i a P r e s s , 1980), pp. 179-202. 2 * For a d i s c u s s i o n o f t r a d i t i o n a l medical systems i n East A f r i c a , see: J.R. Weisz, "East A f r i c a n M e d i c a l A t t i t u d e s , " S o c i a l S c i e n c e and Medicine, 6 (1972), pp. 323-333. For two perspectives~on"*the~ i n c o r p o r a t i o n of t r a d i t i o n a l medical systems i n PHC programmes, see: Wolfgang Bichmann, "Primary Health Care and T r a d i t i o n a l Medicine — C o n s i d e r i n g the Background of Changing Health Care Concepts i n A f r i c a , " S o c i a l Science and Medicine, 13B (1979), pp. 175-182; and, David W. ""Dunlop, " A l t e r n a t i v e s t o 'Modern* Health D e l i v e r y Systems i n A f r i c a ; p u b l i c P o l i c y Issues o f T r a d i t i o n a l Health Systems," S o c i a l S c i e n c e and Medicine, 9 (1975), pp. 581-586. 2 2 See; Sjaak Van Der Geest, Primary Health Care i n Medicine, and P s y c h i a t r y , 365-3837 "The Secondary Importance of South Cameroon," Cultuj-e. 6: 4 (December 1982) ,~ pp. 2 3 C f . UNICEF/WHO I n t e r r e g i o n a l Study and Workshop, Primary, Health Care: The Community Health Worker [Kingston,. Jamaica: World H e a l t h O r g a n i z a t i o n and the United Nations I n t e r n a t i o n a l C h i l d r e n ' s Emergency Fund, 1979/1980), esp. p. 35. 2 * C f . UNICEF-WHO J o i n t Committee on Health P o l i c y Report, 48 Community Involvement i n Primary. Health, Care: A Study of the Process of Community M o t i v a t i o n and Continued P a r t i c i p a t i o n (Geneva: World Health O r g a n i z a t i o n , 1977), esp. p. 10. 2 s George F o s t e r , "Community Development and Primary Health Care: T h e i r Conceptual S i m i l a r i t i e s , " Medical; Anthropology, 6 (1982), p. 192. 2 6 R.B. I s e l y , " R e f l e c t i o n s on an Experience i n Community P a r t i c i p a t i o n i n Cameroon," Annales de l a S o c i e t e beige de Medicine t r o p i c a l e , 59 (1979), Suppl., p. 114. 2 7 See: Frank Hoimquist, "Class S t r u c t u r e and R u r a l S e l f - H e l p i n Kenya and Tanzania," A f r i c a n Review, 6:2 (1976), p. 7. 2 8 Jomo Kenyatta, * Harambee!' The Prime M i n i s t e r of Kenya's  Speeches 1963-1964 [ N a i r o b i : Oxford U n i v e r s i t y P ress, 1964) , p. 7. 2 9 F o r the etymology of harambee i n the p o l i t i c a l economy of the R e p u b l i c of Kenya, see: John H.O., Orora and Hans S.C* S p i e g e l , "Harambee: S e l f - H e l p Development P r o j e c t s i n Kenya," I n t e r n a t i o n a l J o u r n a l of Comparative, S o c i o l o q y , XXI: 3-4 ( T 9 8 0 f 7~sp. p."244. 3 0 see: M a r t i n H i l l , "The Roots of Harambee," New S o c i e t y , 34:689 (1975) , p. 644. 31 P.M. M b i t h i and R. Rasmusson quoted i n : John H.O. Orora and Hans B.C. „•• S p i e g e l , "Harambee: S e l f - H e l p Development P r o j e c t s i n Kenya," I n t e r n a t i o n a l J o u r n a l of Comparative  S o c i o l o g y , XXI:3-4 (1980), p. 244. 32 See: E.M. Godfrey and G.C.M., Mutiso, "The P o l i t i c a l Economy of S e l f - H e l p ; Kenya's "Harambee" I n s t i t u t e s of Technology," Canadian J o u r n a l of A f r i c a n S t u d i e s , 8:1. (1974), pp. 109-133. 33 See: M a r t i n H i l l , "The Roots of Harambee," New S o c i e t y , 34:689 (1975), pp. 644-646. 3* I b i d . , p. 646. T h i s i n f o r m a t i o n i s a l s o confirmed i n a p e r s o n a l i n t e r v i e w with the S e n i o r Health Care Planner, M i n i s t r y of Health headquarters, N a i r o b i , Kenya. 3 5 See; John H-0« Orora and Hans B.C. S p i e g e l , "Harambee: S e l f - H e l p Development P r o j e c t s i n Kenya," i n t e r n a t i o n a l J o u r n a l of Comparative S o c i o l o q y , XXI:3-4 (1980), p. 249*7 3 6 Quoted i n i b i d . , p. 245. 49 3 7 Frank Holmguist, " C l a s s S t r u c t u r e , Peasant P a r t i c i p a t i o n , and Rural S e l f - H e l p , " In J o e l D. Barkan (ed.) with John, J . .. Ok urn a, g o l i t i c s and P u b l i c Policy, i n Kenya and Tanzania (New York, London, Sydney, and Toronto: Praeger P u b l i s h e r s , 1979), p. 139. See as w e l l : S.E. Migot-Adholla, " R u r a l Development P o l i c y and E g u a l i t y , " In i b i d . , esp. p. ,163. 3 8 Frank Holmguist, " C l a s s S t r u c t u r e and R u r a l S e l f - H e l p i n Kenya and Tanzania," A f r i c a n Review, 6:2 (1976), esp. p. 248. 3 9 E. M» Godfrey and G.C.M. Mutiso, "The P o l i t i c a l Economy of S e l f - H e l p : Kenya's "Harambee" I n s t i t u t e s o f Technology," Canadian J o u r n a l of A f r i c a n S t u d i e s , 8:1 (1974), p. 121. 4 0 Henry Bienen, Kenya: The P o l i t i c s of P a r t i c i p a t i o n and C o n t r o l ( P r i n c e t o n , New Jerse y : P r i n c e t o n U n i v e r s i t y P ress, 1974), pp. 42-43. * i V i c t o r i a B r i t t a i n , " F i v e Months That Took Kenya To The B r i n k , " The Guardian, 8 August 1982, p. 7. 4 2 John J . Okumo, "Party and P a r t y - S t a t e R e l a t i o n s , " I n J o e l D. Barkan (ed.) with John J . Okuma, P o l i t i c s and P u b l i c P o l i c y i n Kenya and Tanzania (New York, London, Sydney, and Toronto: Praeger P u b l i s h e r s , 1979), p. 57. 4 3 Henry Bienen, Kenya; The P o l i t i c s of P a r t i c i p a t i o n and C o n t r o l [ P r i n c e t o n , New Jersey: P r i n c e t o n U n i v e r s i t y Press,"~1974) , p. 141; see as w e l l p. 29. 4 4 See: E.g. Godfrey and G.C.M. Mutiso, "The P o l i t i c a l Economy of S e l f - H e l p : Kenya's "Harambee" I n s t i t u t e s of Technology," Canadian J o u r n a l of African, S t u d i e s , 8:1 (1974) , p. 111. 4 5 See i n p a r t i c u l a r the w r i t i n g s of these i n f l u e n t i a l Luq l e a d e r s ; Tom Hboya, Freedom and A f t e r [London: Andre, Deutsch, 1963) ; and Oginga Odinga, Not Y§.t Uhuru: An Autobiography (London; Heinemann, 1967)., 4 6 J o e l D. Barkan suggests th a t ; development i s an i n h e r e n t l y e t h i c a l phenomenon, a s e t of value judgements about what c o n s t i t u t e s the good s o c i e t y and about the i n s t i t u t i o n s and processes through which the good s o c i e t y can be a c h i e v e d . See: J o e l 0. Barkan, "Comparing P o l i t i c s and P u b l i c P o l i c y i n Kenya and Tanzania," In J o e l D. Barkan (ed.) with John J . okumu, P o l i t i c s and P u b l i c P o l i c y i n Kenya 50 and Tanzania (New York, London, Sydney, and Toronto: Praeger P u b l i s h e r s , 1979), p. 12. 4 7 See: John J , Okumu, "Pa r t y and P a r t y - S t a t e R e l a t i o n s , " In J o e l D. Barkan (ed.) with John J . , Okumu, P o l i t i c s aja<| g u b l i c P o l i c y i n Kenya and Tanzania (New York, London, Sydney, and Toronto; Praeger P u b l i s h e r s , 1979), p. 59. * 8 See: V i c t o r i a B r i t t a i n , " F i v e Months That Took Kenya To The B r i n k , " The Guardian. 8 August 1982, p. 7. I n J u l y of 1982 the e d i t o r o f Thje. Standard, a Kenyan newspaper, was f o r c e a b l y dismissed f o r p u b l i s h i n g an e d i t o r i a l c a l l i n g on the Government to r e l e a s e those persons who have been det a i n e d without t r i a l . The t e x t o f t h i s e d i t o r i a l was subsequently r e p u b l i s h e d i n : George G i t h i i , "Speaking Out Of Turn I n Kenya," The Guar_dian, 1 August 1982. 5 0 See: P h i l i p M. M b i t h i , "'Harambee; 1 S e l f - H e l p : The Kenyan Approach," The Kenyan Review, 2:1 (June 1972), pp. 15 7 f f -5 1 Frank Holmguist, " C l a s s S t r u c t u r e , Peasant P a r t i c i p a t i o n , and R u r a l S e l f - H e l p , " In J o e l D. Barkan (ed.) with John J . Okumu, P o l i t i c s and P u b l i c P o l i c y i n Kenya and Tanzania [Mew York, London, Sydney, and Toronto: Praeger P u b l i s h e r s , 1979), p. 131. sz P h i l i p M. M b i t h i , "'Harambee:' S e l f - H e l p : The Kenyan Approach," The A f r i c a n Review, 2:1 (June 1972), p. 160. 5 3 I b i d . s* I b i d . , pp. 155-156. ss I b i d . , pp. 158-161. 5 6 Miriam K. Were, " R u r a l Women's P e r c e p t i o n s and Community-Based Health Care," East African. Medical J o u r n a l , 54:10 (October 1977), p. 529. 5 7 See: P.M. M b i t h i , " I s s u e s i n Rural Development i n Kenya,'»• E a s t A f r i c a J o u r n a l , 9:3 (March 1972), pp. 18-22. .. 5 8 See: Kenelm B u r r i d g e , Mambu [London: Methuen, 1960) ; Hew Heaven, New Ear t h (Oxford; B a s i l B l a c k w e l l , 1969) ; Encountering A b o r i g i n e s (London and New York: Pergamon Press, 1973); and Someone, No One ( P r i n c e t o n , New J e r s e y : P r i n c e t o n U n i v e r s i t y P r e s s , 1979). 5 9 Arguing t h a t one must s e l e c t a vantage-point from which to view the t o t a l i t y of a c u l t u r e , Elkana c l a i m s that " s c i e n c e " i s the most important dimension of Western c u l t u r e ; see: Yehuda Elkana, "A Programmatic Attempt a t 51 an Anthropology of Knowledge," In E v e r e t t Mendelsohn and Yehuda Elkana (eds.) Sciences and C u l t u r e : A n t h r o p o l o g i c a l and H i s t o r i c a l S t u d i e s of the Sciences (Dordrecht, Boston, and London: D. E e i d e l P u b l i s h i n g Company, 1981), esp. pp. 8 f f . 6 0 Kenelm B u r r i d g e , someone, Mo One {Princeton, New J e r s e y : P r i n c e t o n U n i v e r s i t y Press, 1979), p. 92. 6 * I b i d . , p. 93. *z I b i d . , pp. 93-94. «3 I b i d . , p. 97. ** I b i d . , pp. 95-96; see as w e l l p...188. A d i s t i n c t i o n between those s o c i a l orders which do or do not use money i s a l s o provided i n : Kenelm B u r r i d g e , fle.w. Heaven, New E a r t h (Toronto: The Copp C l a r k P u b l i s h i n g Company, 1969),~pp7 41-46., 6 5 Kenelm B u r r i d g e , Someone, No One ( P r i n c e t o n , New J e r s e y : P r i n c e t o n U n i v e r s i t y P r e s s , 1979), p. 98. 6 6 I b i d . , pp. 105-106, 6 7 on r e l a t i o n s h i p s with the ' n o n - r e c i p r o c a l o t h e r , ' see i n p a r t i c u l a r : Kenelm B u r r i d g e , " L e v e l s of Being," i n Gene Outka and John P. Beeder Jr» (eds.), R e l i g i o n arid; M o r a l i t y (New York; Anchor Books, Doubleday, 1973)., 6 8 see: Kenelm B u r r i d g e , New Heaven, New E a r t h (Toronto: The Copp C l a r k P u b l i s h i n g Company, 1969), p. 6. 6 9 I b i d . , pp. 6-7. *o See: I b i d . , esp. p. 144. 7 * Kenelm B u r r i d g e , Someone, No One ( P r i n c e t o n , New J e r s e y : P r i n c e t o n U n i v e r s i t y P r e s s , 1979), p. 9. 7 2 I b i d . , p. 5. 7 3 I b i d . 7 * I b i d . , p. 74. 7 5 Burridge e x p l i c a t e s 'myth-dream* t h i s way: As a concept 'myth-dream' does not l e n d i t s e l f t o p r e c i s e d e f i n i t i o n . N e v e rtheless, myth-dreams e x i s t , and they may be reduced to a s e r i e s o f themes, p r o p o s i t i o n s , and problems which are to be 52 found i n myths, i n dreams, i n the h a l f - l i g h t s of c o n v e r s a t i o n , and i n the emotional responses to a v a r i e t y of a c t i o n s , and guestions asked., Through t h i s k i nd of i n t e l l e c t u a l i z a t i o n myth-dreams become ' a s p i r a t i o n s ' . . . . . .. such i n t e l l e c t u a l i z a t i o n s as are made may become the d e f i n i t i v e p r i n c i p l e s upon which a group o f persons may organize themselves i n t o a v i a b l e party or movement. and by so o r g a n i z i n g themselves the group concerned puts i t s e l f i n t o a p o s i t i o n from which i t may 'capture' the myth-dream by s y m b o l i z i n g and p u t t i n g i n t o e f f e c t the p r o p o s i t i o n s c o n t a i n e d i n the myth-dream. Having done so, having captured what appears as a mainspring of community a c t i o n , the group concerned may harness t h i s power to serve a community or s e c t i o n a l i n t e r e s t . Kenelm B u r r i d g e , Mambu; a Melanesian M i l l e n i u m (London; Methuen, 1960), p. 148. 7 6 Kenelm Burridge, Someone, No One [ P r i n c e t o n , New J e r s e y ; P r i n c e t o n U n i v e r s i t y P r e s s , 1979), p. 74. Chapter I I THE PROBLEM OF "COMMUNITY-BASED HEALTH CARE": THE CASE OF THE MINISTRY OF HEALTH, REPUBLIC OF KENYA 2.1 INTRODUCTION "To the community the Community Hea l t h Worker (CHW) i s t h e i r l o c a l doctor"» Of the t h r e e e t h n o g r a p h i c cases i n t h i s t h e s i s , the M i n i s t r y of Health i l l u s t r a t e s most d r a m a t i c a l l y the problem of implementing mutually s u p p o r t i v e systems of h e a l t h care i n CBHC programmes. For CBHC programmes to emerge as a u t h e n t i c , s i t u a t i o n a l l y r e l e v a n t h e a l t h care s t r a t e g i e s , i t was p o s i t e d t h a t a d i a l o g u e , encounter or democratic exchange of i d e a s be f r e e l y communicated between the two s o c i a l systems: t h a t of the l e a d e r s of the community i n which a programme i s t o be implemented, and r e p r e s e n t a t i v e s of the c l i n i c a l i n f r a s t r u c t u r e which f u n c t i o n s as a r e f e r r a l back-up f o r the CBHC programme.„ In c h a p t e r s 3 and 4, i t w i l l be shown t h a t i n contexts where a d i a l e c t i c i s t o l e r a t e d the ground i s f e r t i l e f o r the emergence of enduring and s e l f - s u s t a i n i n g CBHC programmes. In the case of the M i n i s t r y of Health's proposed and c u r r e n t l y implemented p i l o t p r o j e c t s i n CBHC, the p o s s i b i l i t i e s f o r c o n s t r u c t i n g v i a b l e and mutually suppqrt - 53 -54 CBHC programmes are l i m i t e d . I t i s t h i s problem and the e v e n t u a l i t y 2 of CBHC as i t i s p e r c e i v e d by o f f i c i a l s w i t h i n the M i n i s t r y o f Health t h a t I examine i n t h i s c h a pter. In an attempt t o e x p l a i n and i n t e r p r e t t h i s s i t u a t i o n , I w i l l : (i) r e c o n s t r u c t the b u r e a u c r a t i c s e t t i n g and background f o r the development of a CBHC n a t i o n a l p o l i c y , and ( i i ) , d e l i n e a t e the lineaments of the c u l t u r e and epistemology of h e a l t h care t h a t t h r e a t e n s the p o t e n t i a l e f f e c t i v e n e s s of t h i s supplementary h e a l t h care s t r a t e g y . The problems t h a t emerge i n the government-directed CBHC programmes w i l l be manifested i n the response of r u r a l communities t o the M i n i s t r y of Health's Community Health Worker (CHW). I n t e r n a t i o n a l h e a l t h c a r e , a i d , r e s e a r c h , and donor o r g a n i z a t i o n s have s t r o n g l y urged Kenyan o f f i c i a l s to implement CBHC i n f u t u r e h e a l t h care plans and p r o p o s a l s . While the government's response to t h i s c a l l has been f a v o u r a b l e , the a c t u a l i n t e r p r e t a t i o n and r e c e p t i o n of the CBHC model i s l e s s than encouraging., I suggest t h a t the r e s i s t a n c e and u n d e r l y i n g o p p o s i t i o n t o the CBHC s t r a t e g y — even though i t i s r h e t o r i c a l l y applauded by h e a l t h care_ managers as a j u s t and e s s e n t i a l h e a l t h care t a c t i c — can be a t t r i b u t e d t o the r i g i d i t y of the M i n i s t r y of Health's b u r e a u c r a t i c s t r u c t u r e and the predominant i n f l u e n c e of the c u l t u r e of biomedicine ( a c t u a l i z e d i n the power wielded by b i o m e d i c a l l y t r a i n e d p r o f e s s i o n a l s ) . 55 These t h r e e p e r s p e c t i v e s and the r e l a t i o n s between them — i d e o l o g y , bureaucracy, and the c u l t u r e of biomedicine — a l l play a s i g n i f i c a n t p a r t i n e x p l a i n i n g t h e CBHC drama. Whereas some r e l a t i o n s c o n s t r a i n the a u t h e n t i c development of CBHC programmes and compete i n some r e s p e c t s with t h e i r implementation (e.g., biomedicine and bure a u c r a c y ) , c e r t a i n i n f l u e n c e s and symbols i n the p o l i t i c a l economy l e g i t i m a t e and encourage the g o a l s and o b j e c t i v e s o f CBHC ( i d e o l o g y ) . From an i d e o l o g i c a l p e r s p e c t i v e , there i s no problem with the n o t i o n o f CBHC. The p r e v a i l i n g p o l i t i c a l and economic philosophy of Harambee ( s e l f - h e l p development) argues f o r the development of the n a t i o n through the s e l f - r e l i a n t e f f o r t s of r u r a l peasant communities. Harambee — which emphasizes community involvement and p a r t i c i p a t i o n — i s a l s o i n accord with the r e s o l u t i o n s on Primary Health Care (PHC) o r CBHC agreed upon by WHO and ONICEF. Most s i g n i f i c a n t l y , however, i s the f a c t t h a t i n Kenya i t s e l f , t r a d i t i o n a l , r u r a l - b a s e d communities have been i n v o l v e d i n unique forms, of "community-based h e a l t h c a r e " a l l along.: That i s , they have r e l i e d on community-derived t h e r a p e u t i c s t r u c t u r e s t o h e a l the p a t h o l o g i e s and i l l n e s s e s experienced by t h e i r members. The p r o f e s s i o n a l commitments of a d m i n i s t r a t o r s , p h y s i c i a n s , and nurses underscores a l t e r n a t i v e emphases,, g o a l s , and o b j e c t i v e s . Within the M i n i s t r y o f H e a l t h , the a d m i n i s t r a t o r s i n charge of h e a l t h care p o l i c y are u s u a l l y 56 p r o f e s s i o n a l l y t r a i n e d p h y s i c i a n s . By and l a r g e they are r o o t e d i n the s c i e n t i f i c t r a d i t i o n of b i omedicine and committed to a c l i n i c a l ( curative) h e a l t h c a r e p e r s p e c t i v e , When confronted with the demands of donor agencies f o r a commitment t o CBHC, t h e i r response r e f l e c t s t h i s c l i n i c a l b i a s . CBHC programmes are planned on a n a t i o n a l s c a l e without the s o c i a l and c u l t u r a l a p p r e c i a t i o n of community i n c e n t i v e s , s e l f - d e t e r m i n i s m , and h e a l t h c a r e wisdom., A c o r o l l a r y of t h i s system of biomedical c o n t r o l s i s the b u r e a u c r a t i c s t r u c t u r e of c o n t r o l s w i t h i n the M i n i s t r y of H e a l t h . As an a d m i n i s t r a t i v e l y top-heavy ( c e n t r a l l y c o n t r o l l e d ) bureaucracy, the M i n i s t r y of H e a l t h i s i n c a p a b l e of implementing (at the present time) the p r i n c i p l e s and o b j e c t i v e s of CBHC. I t i s an o r g a n i z a t i o n a l l y r i g i d and i n f l e x i b l e s t r u c t u r e . C o n t r o l l e d by Western-Strained p h y s i c i a n s , the M i n i s t r y of Health can u n f o l d and implement e x i s t i n g h e a l t h care s t r a t e g i e s , but i t i s s t r u c t u r a l l y (and o r g a n i z a t i o n a l l y ) debarred from responding to i n n o v a t i v e s t r a t e g i e s , or from e n t e r t a i n i n g a d i a l o g u e and exchange of i d e a s on a l t e r n a t i v e p e r s p e c t i v e s . With harambee programmes, the government was unable to respond e f f e c t i v e l y and p r e c i s e l y t o the v a r i a b i l i t y of t r i b a l , e t h n i c * and c u l t u r a l l y p r e d i c a t e d h e a l t h care needs. CBHC programmes promise as w e l l to d i m i n i s h the t r u s t and f a i t h of the wananchi (average c i t i z e n ) i n t h e i r government., 57 As such, the model f o r CBHC programmes t h a t i s c u r r e n t l y b e i n g formulated w i t h i n the M i n i s t r y of H e a l t h i s b u r e a u c r a t i c a l l y heavy and b i o m e d i c a l l y dominant i n a d m i n i s t r a t i o n . I t proposes t o extend the network of government h e a l t h c a r e workers i n t o the most p e r i p h e r a l l e v e l of the system [ i . e . r u r a l - b a s e d peasant communities)... Community Hea l t h Workers (CHWs) — whom the M i n i s t r y of H e a l t h suggests would be remunerated by the communities who s e l e c t them — would be t r a i n e d and s u p e r v i s e d by government personnel at the D i s t r i c t l e v e l . I t i s not s u r p r i s i n g to witness, t h e r e f o r e , a l a c k of understanding and commitment on the part of r u r a l peasant communities t o t h i s k i n d of government-inspired CBHC programme. To members of r u r a l communities, t h i s i s not CBHC as they would p r e f e r i t — i . e . , d e r i v e d from a mutual exchange of ideas and systems of support —• but r a t h e r another extension of the government's h e a l t h care system from i t s headquarters i n N a i r o b i (see F i g u r e 3) . I n t h i s c hapter, these u n d e r l y i n g e p i s t e m o l o g i c a l r e l a t i o n s , which are r e f r a c t e d i n the person of the CHW,. w i l l be i n t e r p r e t e d through the process of r e - c o n s t r u c t i n g the emergent view of the MOH on CBHC. I s e p a r a t e t h i s process of c o n s t r u c t i o n i n t o the three moments o f (i), c o n c e p t u a l i z a t i o n , ( i i ) o r g a n i z a t i o n , and ( i i i ) management of a n a t i o n a l CBHC programme. And yet, even t h i s apparent view of the M i n i s t r y of H e a l t h i s bound to change. As i s 58 F i g u r e 3. S i t e o f M i n i s t r y o f H e a l t h - H e a d q u a r t e r s i n N a i r o b i , Kenya Adapted from: The World Bank, Kenya: P o p u l a t i o n and Development (Washington, D.C.: Development Economics Department, E a s t A f r i c a C o u ntry Programs Department, The World Bank, 1980), Regions and D i s t r i c t s Map. 59 i n d i c a t e d i n the most r e c e n t p o l i c y s t a t e m e n t s 3 of the M i n i s t r y of Health toward CBHC, i t i s s t i l l "experimenting" with t h i s p a r t i c u l a r h e a l t h care s t r a t e g y . * The evidence used i n t h i s chapter i s based on i n t e r p r e t a t i o n s from M i n i s t r y of Health (and other Government) documents t h a t were publ i s h e d and p e r s o n a l i n t e r v i e w s t h a t occurred up u n t i l June of 1981. 2.2 THE CONCEPTUALIZATION OF AN INFORMAL "COMMUNITY-BASED HEALTH CASE" POLICY ... the r e s p o n s i b i l i t y f o r the improvement of q u a l i t y of l i f e l i e u l t i m a t e l y i n the community i t s e l f . The most important resource i n the whole development drama i s the community i t s e l f . . . ... change agents are s h o r t term measures or s t r a t e g i e s f o r l o n g term development. Real long term meaningful development must s t r e n g t h e n community i d e a s and i n s t i t u t i o n s . S h i s process r e q u i r e s more f a c t s about the r e a l i t y of community. But f a c t s , must be above a l l , complemented by common sense, i m a g i n a t i o n and a l o t of i n t u i t i o n . 5 2.2.1 The B u r e a u c r a t i c Context In t h i s s e c t i o n , I attempt t o unravel the f a c t o r s which i n f l u e n c e the c o n c e p t u a l i z a t i o n of a CBHC programme w i t h i n the M i n i s t r y of H e a l t h . Even though the M i n i s t r y of Health may p u b l i c l y d e c l a r e i t s a l l e g i a n c e to the p r i n c i p l e s and o b j e c t i v e s of Primary Health Care (PHC), the everyday r e a l i t y of the h e a l t h care planning environment communicates other commitments and a l l e g i a n c e s . Within the s t r a t e g i c domain of p o w e r f u l l y p l a c e d i n d i v i d u a l s i n the M i n i s t r y , 60 d e c i s i o n s are o f t e n made t h a t are not so much a r e f l e c t i o n o f s t a t e d p o l i c y , but r a t h e r , the p o l i t i c a l i n t e r e s t of the i n d i v i d u a l i n question,.* There i s , however, a c e r t a i n amount of pressure to conform to p r e v a i l i n g p o l i t i c a l views and of c o u r s e the economic r e a l i t i e s of the M i n i s t r y of H e a l t h . , So while an upper l e v e l manager may have the power t o a l l o c a t e more of the s c a r c e r e s o u r c e s of the h e a l t h s e c t o r to h i s own home D i s t r i c t , he may adamantly voice a commitment to equal d i s t r i b u t i o n throughout the country. S i m i l a r l y , i f t h i s a d m i n i s t r a t o r i s convinced t h a t the "modern" t h i n g t o do i s t o develop a more e x t e n s i v e network of s t a t i c health, f a c i l i t i e s , he may s t i l l be compelled to argue f o r CBHC programmes which emphasize disease p r e v e n t i o n and h e a l t h promotion. T h i s i s p a r t i c u l a r l y true when other m i n i s t r i e s w i t h i n the Government are convinced of a p a r t i c u l a r development tack as was the case when the M i n i s t r y of Finance and P l a n n i n g argued f o r a CBHC approach. Policy-makers w i t h i n the M i n i s t r y of Health are compelled to c o n s i d e r fundamental p o l i t i c a l m o t i f s and themes. Jqmq. Kenyatta*s p o l i t i c a l p h i l osophy of Harambee i d e n t i f i e d s e l f - r e l i a n c e and s e l f - d e t e r m i n a t i o n as being the e s s e n t i a l f o r c e i n the development process. D a n i e l arap Moi,_ Kenyatta*s named s u c c e s s o r as P r e s i d e n t of the R e p u b l i c of Kenya, has propounded the motto of Nyayo ( K i s w a h i l i f o r " i n h i s f o o t s t e p s " ) which demonstrates h i s indebtedness to h i s predecessor as w e l l as h i s i n t e n t i o n to a s s e r t s i m i l a r 61 p r i n c i p l e s of s e l f - r e l i a n c e and s e l f - d e t e r m i n a t i o n . Consequently, Harambee (Self-Help) i s s t i l l very much the s t a t e d theme of the present government and i n f l u e n c e s c u r r e n t development o b j e c t i v e s and g o a l s . I t i s understood t h a t s e l f - h e l p processes r e q u i r e ... at l e a s t a minimum of community o r g a n i z a t i o n , involvement, and i n i t i a t i v e , and a community c o n t r i b u t i o n of f i n a n c e and l a b o u r , or both, to any p r o j e c t . 7 In the r u r a l areas, s e l f - h e l p p r o j e c t s are e v i d e n t i n the b u i l d i n g of s c h o o l s , roads, h e a l t h f a c i l i t i e s , and community c e n t r e s . 8 S e l f - h e l p (or harambee) a c t i v i t i e s have come to. mean the process to a c h i e v e development. In o t h e r words, i n an e f f o r t to modernize and/or "develop themselves," peasants c o l l e c t i v e l y o r g a n i z e themselves a t the community l e v e l f o r the purpose of a c q u i r i n g p u b l i c and s o c i a l l y used a m e n i t i e s . Policy-makers w i t h i n t h e M i n i s t r y of H e a l t h are a l s o i n f l u e n c e d by p o l i t i c a l themes and mottos generated by the i n t e r n a t i o n a l h e a l t h c a r e community. HHO/UNICEF*s o b j e c t i v e of " h e a l t h f o r a l l by the year 2,000" i s one such decree, at a p u b l i c p o l i c y l e v e l , the D e c l a r a t i o n of Alma-Ata r e i n f o r c e s Kenya's e x i s t i n g philosophy of s e l f - h e l p ; i n the achievement of Primary Health Care or CBHC, governments are encouraged t o a p p r o p r i a t e the human resources of t h e i r r u r a l communities i n the i n i t i a t i o n , p l a n n i n g , and management of the CBHC programmes. And yet, from the p e r s p e c t i v e of M i n i s t r y o f Health o f f i c i a l s , there i s cause t o s u b s c r i b e t o t h i s p o l i c y f o r economic and not simply p o l i t i c a l reasons. 62 In the "development b u s i n e s s , " p o l i c i e s and pl a n s are made to get ooaSI* 9 & t t n e present time, donors and a i d o r g a n i z a t i o n s i n t e r e s t e d i n Kenya's h e a l t h s e c t o r have been i n f l u e n c e d by t h e World Health O r g a n i z a t i o n 1 s (WHO) p o s i t i o n on Primary Health Care (PHC) and are now demanding that s p e c i f i c requirements and procedures be f u l f i l l e d b e f o r e the promise o f economic a s s i s t a n c e i s given., In the process of planning f o r the I n t e g r a t e d R u r a l H e a l t h and Family P l a n n i n g programme (IRH-FP), the World Bank Missi o n i s c o o r d i n a t i n g most of the d e l i b e r a t i o n s between M i n i s t r y of Health, o f f i c i a l s and i n t e r e s t e d donors. The Bank i s i n s i s t i n g t h a t donors act i n a un i t e d f a s h i o n and most d e f i n i t e l y around the key p r i n c i p l e of CBHC. Ac t i n g independently as w e l l as c o r p o r a t e l y , the l a r g e m a j o r i t y of donors t r a d i t i o n a l l y i n v o l v e d i n Kenya's h e a l t h s e c t o r — i . e . United S t a t e s Agency f o r I n t e r n a t i o n a l Development (USAID), Swedish I n t e r n a t i o n a l Development A u t h o r i t y (SIDA) , and Danish, I n t e r n a t i o n a l Development Agency (DANIDA) — are i n t e r e s t e d i n developing the CBHC i n f r a s t r u c t u r e i n t h i s proposed I n t e g r a t e d R u r a l H e a l t h and Family P l a n n i n g programme (IRH-FP) . , Over and above the economic and p o l i t i c a l i n f l u e n c e s c a l l i n g f o r an a l t e r n a t i v e h e a l t h c a r e s t r a t e g y , t h e r e are the p r e c i p i t a t i n g i n f l u e n c e s within the M i n i s t r y of Health i t s e l f . A number of r e s e a r c h s t u d i e s c a r r i e d out by h e a l t h p r o f e s s i o n a l s employed by the M i n i s t r y of Health and by 63 h e a l t h p r o f e s s i o n a l s a t t a c h e d to the F a c u l t y of Medicine at the U n i v e r s i t y of N a i r o b i have exposed the s e r i o u s d e f i c i e n c i e s of the e x i s t i n g r u r a l h e a l t h s e r v i c e system. One such study c a r r i e d out i n Hachakos D i s t r i c t i n d i c a t e s t h a t p r e v e n t i v e s e r v i c e s i n p a r t i c u l a r are u n d e r - u t i l i z e d or r a r e l y used.* 0 Another study by an independent c o n s u l t i n g f i r m commissioned by the R u r a l Health Development P r o j e c t of the M i n i s t r y of H e a l t h , produced the same r e s u l t s . In K i t u i D i s t r i c t , they found t h a t p r e v e n t i v e h e a l t h s e r v i c e s i n t h i s r u r a l area were u n d e r - u t i l i z e d . 1 1 The most c e l e b r a t e d h e a l t h care r e s e a r c h study o f the l a s t decade i n Kenya suggested t h a t most of the d i s e a s e s a f f l i c t i n g Kenyans were preventable. In t h i s r e p o r t t h a t was sponsored by the M i n i s t r y of Health i n c o l l a b o r a t i o n with the World Health O r g a n i z a t i o n , the r e s u l t s i m p l i e d t h a t the problem was s i t u a t e d i n : (i) the h e a l t h system i t s e l f , and ( i i ) i n the s o c i a l and c u l t u r a l c o n d i t i o n s of the r e c i p i e n t p o p u l a t i o n s [see F i g u r e 4) . From the p e r s p e c t i v e of M i n i s t r y of Health o f f i c i a l s the n a t u r a l tendency was to c r i t i c i z e the r e c i p i e n t p o p u l a t i o n r a t h e r than the s t r u c t u r e of the d e l i v e r y system. I t i s e s s e n t i a l t o a p p r e c i a t e the s i g n i f i c a n c e of these p o l i t i c a l , economic, and p r o f e s s i o n a l f a c t o r s a t t e n d a n t on. the M i n i s t r y of Hea l t h ' s c o n c e p t u a l i z a t i o n of a CBHC programme. In the c h r o n i c l e 1 2 of s p e c i f i c p l a n n i n g and p o l i c y events t h a t f o l l o w s , the substance and c h a r a c t e r of Figure Kenya Community 4. Nurse (KCN) Photograph of Kenya Community Nurse (KCN) weighing c h i l d and recording c h i l d ' s "Road to Health" chart at the Chulaimbo Ru Health Training Centre (RHTC) near Kisumu, Kenya 65 the phenomenal r e l a t i o n s experienced w i t h i n the M i n i s t r y of H e a l t h i s d i s p l a y e d more c l e a r l y . In broad s t r o k e s , the problems w i l l f a l l a l o n g these axes: i ) ^ c u r a t i y e as opposed t o a p r e v e n t i v e h e a l t h care, s t r a t e g y , i i ) an urban versus a r u r a l a l l o c a t i o n of h e a l t h care r e s o u r c e s , and i i i ) a h e a l t h c a r e bureacracy [ i n f l u e n c e d by modernist t r e n d s and b i o d m e d i c a l p r i n c i p l e s ) impinging on t r a d i t i o n a l m edical systems [ c o n s t r a i n e d by s u b s i s t e n c e - b a s e d and peasant-based s o c i a l o r g a n i z a t i o n s ) . a l l of these r e l a t i o n s are played out i n the drama of CBHC. The a c t o r s i n v o l v e d i n the drama r e p r e s e n t e i t h e r the i n t e r e s t s of the M i n i s t r y of Health or r u r a l peasant communities.. I t i s not so much a s t o r y of "bureaucracy" versus "community" as much as a s i t u a t i o n . where each i s misunderstood and t o some extent a v o i d s r e l a t i o n s with the o t h e r . Since t h i s chapter attempts t o uncover the M i n i s t r y of Health's p o i n t of view, I w i l l c o ncentrate on i t ' s p e r s p e c t i v e : i . e . , the " p e r s o n a l i t y " of an o r g a n i z a t i o n that encompasses the m e d i c a l , p r o f e s s i o n a l , and p o l i t i c a l i n t e r e s t s of upper l e v e l a d m i n i s t r a t o r s and d i r e c t o r s . I t w i l l become c l e a r t h a t the M i n i s t r y of H e a l t h i s v i r t u a l l y i n c a p a b l e of c o n c e i v i n g of a r e l a t i o n s h i p of p a r t n e r s h i p [in 66 the management of the proposed CBHC programme) with r u r a l , peasant communities. T h i s r e t i c e n c e and u n c e r t a i n t y on the p a r t of the M i n i s t r y of Health towards t r a d i t i o n a l communities can be a t t r i b u t e d t o the rootedness of the M i n i s t r y of H e a l t h i n Hestern, c l i n i c a l l y - b a s e d medicine, and the a u t h o r i t y t h a t t h i s system of h e a l t h c a r e i s known to invoke; i t a l s o r e f l e c t s the governments need to p o l i t i c a l l y c o n t r o l jobs i n the h e a l t h s e c t o r . T r a d i t i o n a l communities are p e r c e i v e d to be groups of people r e g u i r i n g t r a n s f o r m a t i o n and e d u c a t i o n i n the modernist development and c l i n i c a l h e a l t h c a r e p e r s p e c t i v e . 2.2.2 A C h r o n i c l e of P l a n n i n g and P o l i c y Events i n the Process of C o n c e p t u a l i z i n g Community-Based H e a l t h Care There are f i v e s i g n i f i c a n t planning and p o l i c y events which mark the c o n c e p t u a l i z a t i o n of CBHC as an a l t e r n a t i v e s t r a t e g y f o r r u r a l h e a l t h c a r e s e r v i c e s . These events are p r e d i c a t e d on the p o l i t i c a l , economic, and p r o f e s s i o n a l i n f l u e n c e s p r e v i o u s l y mentioned and i n themselves provide the impetus and r a t i o n a l e f o r subseguent stage s i n the o r g a n i z a t i o n of CBHC programmes. These events c l a r i f y as w e l l the s p e c i f i c c h a r a c t e r and dimension of the tenuous r e l a t i o n s h i p between "government" and "community." 2.2.2.1 P r o p o s a l f o r the Improvement o f B u c a l H e a l t h S e r v i c e s and the Development of B u r a l H e a l t h T r a i n i n g C e n t r e s i n Kenya 67 On august 1, 1972, the m i n i s t r y o f Health i n c o l l a b o r a t i o n with the World Health O r g a n i z a t i o n p u b l i s h e d the Proposal f o r the Improvement of S u r a l H e a l t h S e r v i c e s and the Development of S u r a l Health Training, C e n tres i n K e n y a * 1 3 The r e s u l t s o f t h i s " s i t u a t i o n a l a n a l y s i s " suggested s e r i o u s d e f i c i e n c i e s i n the s t r u c t u r e and content of s e r v i c e s provided i n the r u r a l areas. At the same time, however, blame was p l a c e d on the c l i e n t p o p u l a t i o n i t s e l f . The problem areas were d e l i n e a t e d as f o l l o w s : a) most r u r a l people s t i l l have no medi c a l s e r v i c e w i t h i n e f f e c t i v e reach of t h e i r homes; b) most of the people do not know how t o make the most e f f e c t i v e use of e i t h e r p r e v e n t i v e or c u r a t i v e medical s e r v i c e s , even when they are a v a i l a b l e ; c) most of the h e a l t h workers are not using the most e f f e c t i v e methods i n p r e v e n t i n g i l l n e s s and death, because -i ) they have not been t r a i n e d t o do so; and/or i i ) they a r e not e f f e c t i v e l y s u p e r v i s e d and encouraged i n t h e i r p r a c t i c a l h e a l t h work i n r u r a l f a c i l i t i e s . 1 4 Whereas the apparent problems were rooted i n the s o c i a l and i n t e r p e r s o n a l r e l a t i o n s h i p between " p r o v i d e r " and " c l i e n t " [or " h e a l t h worker" and " p a t i e n t " ) , the suggested recommendations veered towards i n c r e a s i n g s p.e c i a l i z a t jonj w i t h i n the e x i s t i n g system through: (i) r e - t r a i n i n g programmes f o r h e a l t h care workers s t a t i o n e d i n r u r a l areas, and _ i i ) i n c r e a s i n g the h e a l t h know ledge content of programmes. I t was recommended, t h e r e f o r e , t h a t f o l l o w i n g h e a l t h problems be addressed: a) Family h e a l t h , i n c l u d i n g f a m i l y p l a n n i n g . b) Communicable d i s e a s e s . c) Disease arid c o n d i t i o n s r e s u l t i n g from o r provoked by inadequate environmental s a n i t a t i o n . d) H e a l t h problems r e l a t e d to m a l n u t r i t i o n and u n d e r n u t r i t i o n . i S 68 the the 2.2.2.2 The Development P l a n : 1979-1983 The planning venture f o r Kenya*s Fourth N a t i o n a l Development Plan began i n March, 1977 and was f i n a l l y completed i n November, 1978. 1 6 The o v e r a l l theme of the Plan was "the a l l e v i a t i o n o f poverty." To achieve t h i s o b j e c t i v e , the Permanent S e c r e t a r y of the M i n i s t r y of Fin a n c e and Pla n n i n g i n d i c a t e d t h a t development a c t i v i t i e s i n the r u r a l areas would have t o be strengthened. One aspect o f t h i s emphasis would i n v o l v e the de,c§ntra.l,4za.tion of planning a c t i v i t i e s t o the D i s t r i c t * 7 l e v e l : P r e p a r a t i o n of d i s t r i c t plans i s t o proceed simultaneously with p r e p a r a t i o n of the n a t i o n a l p l a n . T h i s i n c r e a s e d accent on d i s t r i c t l e v e l p l a n n i n g r e f l e c t s our i n t e n t i o n to i n v o l v e the l o c a l people i n the pl a n n i n g process to a g r e a t e r extent than i n the p a s t . Planning c a p a c i t y has been strengthened a t the d i s t r i c t l e v e l t o f a c i l i t a t e l o c a l c o n t r i b u t i o n s t o p l a n n i n g , acknowledging the f a c t t h a t i t i s the people f o r whom plans are formulated who are i n the b e s t p o s i t i o n t o know t h e i r needs and p r i o r i t i e s . * 8 69 Within the g e n e r a l g u i d e l i n e s e s t a b l i s h e d by the M i n i s t r y of Finance and P l a n n i n g , M i n i s t r y of He a l t h personnel engaged i n the f o r m u l a t i o n of the h e a l t h s e c t i o n of the Plan were encouraged to address the g e n e r a l o b j e c t i v e of "promoting and p r o t e c t i n g the h e a l t h of the people, with p a r t i c u l a r emphasis g i v e n to the r u r a l p o p u l a t i o n . " T h i s was a recommendation to s h i f t from an emphasis on c l i n i c a l h e a l t h care s e r v i c e s to an emphasis on d i s e a s e p r e v e n t i o n and h e a l t h promotion s e r v i c e s . N e v e r t h e l e s s , planning d i s c u s s i o n s i n e v i t a b l y veered towards c l i n i c a l and c u r a t i v e concerns. For example, i n the August 16, 1977 meeting arranged f o r P r o v i n c i a l M edical O f f i c e r s of Health, the d i s c u s s i o n " c e ntred on the c o n s t r u c t i o n of h e a l t h f a c i l i t i e s and on maintenance of equipment and v e h i c l e s , as w e l l as the problems of drug s u p p l y . " 1 9 Even a f t e r the submission of the f i r s t d r a f t c h a p t e r , t h e r e was cause f o r the Deputy Permanent S e c r e t a r y of the M i n i s t r y of Finance and Planning to c r i t i c i z e the l a c k of resource a l l o c a t i o n g i v e n t o p r e v e n t i v e programmes: The budgetary p r o v i s i o n s are not c o n s i s t e n t with the s t a t e d p r i o r i t i e s . Thus c u r a t i v e h e a l t h i s a l l o c a t e d s u b s t a n t i a l l y more resources than the £reventive h e a l t h programme. Within c u r a t i v e h e a l t h , the proposed investments i n N a i r o b i and Mombasa w i l l worsen the d i f f e r e n t i a l i n h e a l t h f a c i l i t i e s between r u r a l and urban a r e a s . 2 0 When the h e a l t h s e c t i o n of the Plan was f i n a l l y approved and came t o pre s s , these apparent c o n t r a d i c t i o n s were t e m p o r a r i l y r e s o l v e d . The Plan r e i t e r a t e d the o b j e c t i v e s of 70 the 1972 P r o p o s a l (see 2.2.2.1.) f o r the improvement of r u r a l h e a l t h s e r v i c e s ; namely, t h a t a t t e n t i o n would be given to these f o l l o w i n g d i s e a s e prevention and h e a l t h promotion programmes: (a) Communicable and Vector-borne Disease C o n t r o l . (b) Environmental h e a l t h . (c) Family P l a n n i n g / Maternal C h i l d H e a l t h . (d) N a t i o n a l H e a l t h l a b o r a t o r i e s . (e) Health E d u c a t i o n . (f) N u t r i t i o n , a* The P l a n i n d i c a t e d as w e l l that i n an e f f o r t t o a d dress these s t a t e d programme o b j e c t i v e s , a s s i s t a n c e would be given to p r o j e c t s s t a r t e d on a s e l f - h e l p b a s i s . I n g e n e r a l , the Plan s t a t e d t h a t "community and non-government agencies* p a r t i c i p a t i o n w i l l be promoted and encouraged. , , 2 2 The extent to which t r a d i t i o n a l p r a c t i t i o n e r s (midwives and t r a d i t i o n a l b i r t h attendants) c o u l d be i n c o r p o r a t e d i n t o government h e a l t h s e r v i c e s i n the r u r a l areas would a l s o be considered. 23 2.2.2.3 I n t e g r a t e d H u r a l Health S e r v i c e s Programme At the same time t h a t the Development Plan was being formulated, the S e n i o r Deputy D i r e c t o r of M e d i c a l S e r v i c e s [S.D.D.M.S., R u r a l H e a l t h ) , M i n i s t r y o f H e a l t h , proposed a workshop to d i s c u s s an " i n t e g r a t e d " approach t o r u r a l h e a l t h s e r v i c e delivery. 2« He was supported i n t h i s c a l l by the World Bank M i s s i o n . A task f o r c e was c r e a t e d to address an I n t e g r a t e d -Rural H e a l t h S e r v i c e s Prog.ra.mme (ISHS) and the f i r s t meeting was held May 25-27, 1978 at the Outspan H o t e l , N y e r i , Kenya. 71 The Kenyan h e a l t h p r o f e s s i o n a l s p a r t i c i p a t i n g i n the workshop proposed t h a t i n order to achieve i n t e g r a t i o n i n r u r a l h e a l t h s e r v i c e s the people a t the l o c a l l e v e l would need to be i n v o l v e d i n the " p l a n n i n g , implementing and e v a l u a t i n g of v a r i o u s programmes." 2 5 The D i r e c t o r of the N a t i o n a l P i l o t P r o j e c t i n Community-Based Health, Carej (sponsored by UHO/UNICEF) — whose programme was i n i t i a t e d i n September, 1977 — s u b s t a n t i a t e d t h i s c a l l f o r i n t e g r a t i o n u s i n g the argument of a "community-based approach." In the r e p o r t of t h i s Working Seminar, the r a t i o n a l e f o r a CBHC approach i s given as: a) To r e c o g n i z e community c a p a c i t y f o r p a r t i c i p a t i n g i n h e a l t h c a r e and m o b i l i z a t i o n of resources (manpower/material and p h y s i c a l f a c i l i t i e s ) , b) To i n c r e a s e community a w a r e n e s s / p a r t i c i p a t i o n i n h e a l t h promotion, d i s e a s e p r e v e n t i o n and simple c u r a t i v e a c t i v i t i e s . c) To open c h a n n e l s of communication between the community and the e s t a b l i s h e d h e a l t h • • s e r v i c e s . 2 6 As f a r as I can a s c e r t a i n , t h i s i s the f i r s t time t h a t credence i s given by M i n i s t r y of Health o f f i c i a l s t o the f a c t t h a t communities c o u l d p a r t i c i p a t e i n the p l a n n i n g , implementation, and management of h e a l t h c a r e s e r v i c e s i n t h e i r own areas. The recommendation to i n v o l v e r u r a l communities was not p r o v i d e d by an o f f i c i a l o f the M i n i s t r y of Health, however, but by a f a c u l t y member of the. 72 U n i v e r s i t y of N a i r o b i ( i n the Department of Community H e a l t h , F a c u l t y of M e d i c i n e ) . 2.2.2.4 I n t e r n a t i o n a l Conference on Primary H e a l t h Care Kenya's r e p r e s e n t a t i v e s t o the WHO/UNICEF sponsored I n t e r n a t i o n a l Conference on Primary Health Care (held a t Alma-Ata, U.S.S.R., 6-12 September, 1978) r e i t e r a t e d the recommendations made a t the Nyeri Conference.. In the p u b l i s h e d speech g i v e n a t the Conference, the Kenyan o f f i c i a l s t a t e d t h a t ... i t has become imp e r a t i v e t h a t other a l t e r n a t i v e s be e x p l o r e d i f e s s e n t i a l h e a l t h c a r e has to reach each i n d i v i d u a l and f a m i l y i n these under-served and under p r i v i l e g e d r u r a l a r e a s . This means t h a t i f we are a s p i r i n g t o p r o v i d e e s s e n t i a l h e a l t h care f o r a l l by the year 2,000, we w i l l have to generate a d d i t i o n a l c a r e f o r the community through seeking other non-conventional approaches t h a t go beyond the t r a d i t i o n a l c o n v e n t i o n a l s y s t e m s . 2 7 A "two pronged approach" was i d e n t i f i e d as the means f o r a c c o m p l i s h i n g these o b j e c t i v e s , and would i n v o l v e : (a) c l i n i c s and (b) a community-based h e a l t h care s y s t e m . 2 8 A l r e a d y e x i s t i n g c a d r e s of h e a l t h workers c o u l d be u t i l i z e d to f a c i l i t a t e community p a r t i c i p a t i o n through a r e t r a i n i n g programme. They would be o r i e n t e d to the concept of community p a r t i c i p a t i o n and a c t as a c a t a l y s t i n the: (a) d e f i n i t i o n and d e l i n e a t i o n of "community", (b) e s t a b l i s h m e n t o f community h e a l t h committees, (c) o r g a n i z a t i o n of community accounts, and (d) s e l e c t i o n of Community Health W o rkers. 2 9 73 2.2.2.5 An I n t e g r a t e d R u r a l Health and Family P l a n n i n g Programme (IRH/FP) On August 7, 1979, the Permanent S e c r e t a r y of the M i n i s t r y of Economic P l a n n i n g and Community A f f a i r s c a l l e d f o r the " P r e p a r a t i o n of an I n t e g r a t e d R u r a l H e a l t h and Family Planning Programme." 3 0 The p r e l i m i n a r y "Working Document" (dated August 10, 1979) presented t h i s o b j e c t i v e : To improve the coverage and q u a l i t y of b a s i c h e a l t h c a r e f o r the r u r a l p o p u l a t i o n towards the o v e r a l l goal of " h e a l t h f o r a l l by the year 2,000." 3* T h i s document s t r e s s e d t h a t support would be given towards the development of "community-based h e a l t h " a c t i v i t i e s . 3 2 On the b a s i s of a review of the experience gained from d i f f e r e n t programmes i n Kenya, i t was recommended t h a t a f l e x i b l e guide f o r the development of CBHC programmes be prepared. T h i s guide would cover: a) the process of m o b i l i z i n g and s t i m u l a t i n g communities, the advantages and disadvantages o f using s p e c i f i c l o c a l groups as f o c a l p o i n t s (eg. churches, women's groups, c o - o p e r a t i v e s , and the a d m i n i s t r a t i o n and membership of h e a l t h committees).,.; b) the o r g a n i z a t i o n and management of the programme by the community, p a r t i c u l a r l y the f i n a n c i a l c o n t r o l and sources of f i n a n c e ; c) the s e l e c t i o n of Community He a l t h Workers (CHWs) and the r o l e s of community and h e a l t h personnel r e s p e c t i v e l y i n e s t a b l i s h i n g the c r i t e r i a and the s e l e c t i o n process; d) the f u n c t i o n s of Community Health Workers (CHWs), t h e i r remuneration and t h e i r t r a i n i n g ; 74 e) the r o l e o f the h e a l t h system i n o v e r a l l support ... and f) the c o - o r d i n a t i o n with, and s t i m u l a t i o n o f development a c t i v i t i e s i n other s e c t o r s 33 ... The f i n a l document, dated A p r i l 1981, c a l l e d f o r an "experimental" approach towards CBHC: A key element of primary h e a l t h c a r e , or any other h e a l t h c a r e system t h a t attempts wide coverage a t a r e l a t i v e l y low c o s t , i s the use of community h e a l t h workers (CHWs) with l i m i t e d t r a i n i n g t o provide f r o n t - l i n e s e r v i c e and t o r e f e r p a t i e n t s to r u r a l h e a l t h f a c i l i t i e s and h o s p i t a l s . 3 4 2.2.3 A Review o f the Conceptual Process i n the Form u l a t i o n of "Community-Based Health Care" The preceding c h r o n i c l e of pl a n n i n g and p o l i c y events w i t h i n the M i n i s t r y of Health exposes the rough o u t l i n e s of a p a r t i c u l a r p e r s p e c t i v e on "community-based h e a l t h c a r e " (CBHC). Over the l a s t ten years the M i n i s t r y of Health has g r a d u a l l y , and with t r e p i d a t i o n , come to the r e a l i z a t i o n that CBHC must be c o n s i d e r e d as a supplementary s t r a t e g y to e x i s t i n g c l i n i c - b a s e d h e a l t h care d e l i v e r y systems.. The sour c e of f r u s t r a t i o n i n t h i s p l a n n i n g process f o r CBHC programmes i s the conseguent r e a l i z a t i o n t h a t i d e a l l y r u r a l communities are necessary, a c t i v e agents i n t h i s e x e r c i s e . Nevertheless, t h i s l e v e l o f involvement and d e t e r m i n a t i o n i n th e h e a l t h care p l a n n i n g process on the p a r t o f r u r a l communities i s r e p e a t e d l y overlooked. Up t o and i n c l u d i n g the I n t e g r a t e d R u r a l H e a l t h and Family P l a n n i n g Programme 75 (IRfl/FP) d e l i b e r a t i o n s , "communities" are c o n s t r u c t e d t o be r e c i p i e n t / r e s p o n d i n g members i n the pl a n n i n g process, i "Communities" are understood t o be impassive, i n v o l u n t a r y bodies r e q u i r i n g " s t i m u l a t i o n " and " m o b i l i z a t i o n . " For these reasons, i n an e f f o r t to i n v o l v e them i n CBHC they must be a s s i s t e d i n : " d e f i n i n g and d e l i n e a t i n g t h e i r community," " o r g a n i z a t i o n of community accounts," and "establishment of community h e a l t h committees." Why i s i t then, t h a t the M i n i s t r y of H e a l t h p e r c e i v e s r u r a l communities i n t h i s p a r t i c u l a r way; i . e . / as o r g a n i z a t i o n s of t r a d i t i o n a l l y - m i n d e d persons who need t o be t o l d how to thin k and how t o organize themselves? I t i s my i n t e r p r e t a t i o n t h a t the problem i s i n t r i n s i c to the o r g a n i z a t i o n a l ( b u r e a u c r a t i c ) s t r u c t u r e o f the M i n i s t r y and the p o l i t i c a l and p r o f e s s i o n a l p o s i t i o n of o f f i c i a l s w i t h i n i t . any understanding of the c o n c e p t u a l i z a t i o n process of M i n i s t r y of Health o f f i c i a l s on community, and with i t CBHC,, must be i n t e r p r e t e d on the b a s i s of t h i s u n d e r l y i n g r e a l i t y . F i r s t of a l l , a s i g n i f i c a n t c h a r a c t e r i s t i c of the b u r e a u c r a t i c s t r u c t u r e of the M i n i s t r y o f H e a l t h i s that i d e a s , g o a l s , o b j e c t i v e s , and pla n s are d i r e c t e d and l e g i t i m a t e d from the top-down (some of these plans are i n i t i a t e d from o u t s i d e the country — eg., the World Bank and WHO). On o c c a s i o n , d e c i s i o n s are a c t u a l l y made deus ex machina and without the foreknowledge or understanding of those c i v i l s e r v a n t s who w i l l be r e q u i r e d t o c a r r y them out. 76 To r e i t e r a t e M o r i s 1 d e s c r i p t i o n of T h i r d World b u r e a u c r a c i e s , Downward communication i s f a c i l i t a t e d and expected; l a t e r a l communication i s f o r b i d d e n ; and upwards communication except upon re q u e s t not s o u g h t . 3 5 I n the planning e x e r c i s e f o r CBHC programmes, t h e r e f o r e , i t i s c h a r a c t e r i s t i c o f the a d m i n i s t r a t i v e s t r u c t u r e t o make d e c i s i o n s r e g a r d i n g p l a n s , models, and s t r u c t u r e s f o r CBHC without e l i c i t i n g comments from those who work i n r u r a l a r e a s , Communication (and t h e r e f o r e c r i t i q u e ) upwards through the b u r e a u c r a t i c system i s thwarted by d e c i s i o n s a l r e a d y made, or the f a i l u r e of any d e c i s i o n a t a l l (thereby completely i m m o b i l i s i n g e f f e c t i v e d e l i v e r y o f h e a l t h care s e r v i c e s ) . More s p e c i f i c a l l y , i t i s a handful of i n d i v i d u a l s w i t h i n t h i s s t r u c t u r e who make the a d m i n i s t r a t i v e d e c i s i o n s r e g a r d i n g r u r a l h e a l t h c a r e s e r v i c e s , The s i g n i f i c a n t a c t o r s i n t h i s drama are u s u a l l y p o l i t i c a l appointees (by f i a t ) who are a l s o h e a l t h care p r o f e s s i o n a l s . The combined a u t h o r i t y vested i n these p o s i t i o n s f u r t h e r a l i e n a t e s decision-makers from those persons and communities who are a f f e c t e d by them: t h e r e i s the a u t h o r i t y of the medical d o c t o r s who, by v i r t u e of t h e i r t r a i n i n g , a re convinced of the s u p e r i o r i t y of a modern, c l i n i c a l approach t o h e a l t h care d e l i v e r y ; t h e r e i s a l s o the a u t h o r i t y of the s t r a t e g i c a l l y - p l a c e d i n d i v i d u a l who r e p r e s e n t s t r i b a l and d i s t r i c t development i n t e r e s t s . The net r e s u l t can be and 77 o f t e n i s a c o n c r e t i z a t i o n o f planned o b j e c t i v e s and the value a t t r i b u t e d to them. C l i n i c a l care i s j u s t i f i e d and p r a c t i c a l l y r e i f i e d as the d e s i r a b l e h e a l t h c a r e r e a l i t y in, the Government's eyes, and subsequently implemented through, the c o n s t r u c t i o n of h o s p i t a l s , h e a l t h c e n t r e s , and d i s p e n s a r i e s i n areas amenable t o p u b l i c s c r u t i n y and e v a l u a t i o n ( i . e . , densely populated urban a r e a s ) . I t appears t h a t the a d m i n i s t r a t i v e s t r u c t u r e i s so r i g i d l y entangled i n t h i s b u r e a u c r a t i c net, t h a t p r o s p e c t s f o r embarking on a l t e r n a t i v e s t r a t e g i e s (namely, CBHC) s u f f e r s from the c o n t i n u a t i o n of t h i s i n f l e x i b l e s t a t u s <juo.r For example, when f a c e d with the emerging problems a s s o c i a t e d with expanding the c l i n i c a l model i n t o the r u r a l areas — problems of drug d i s t r i b u t i o n and a l l o c a t i o n , v e h i c l e maintenance, and c o n s t r u c t i o n of h e a l t h f a c i l i t i e s a c c o r d i n g to schedule -- the e f f e c t i v e n e s s o f the e x i s t i n g model of h e a l t h care d e l i v e r y i s r a r e l y q u e s t i o n e d . In l i e u of r a d i c a l change, the model i s f o r t i f i e d through i n c r e a s i n g p r o f e s s i o n a l i s m , s p e c i a l i z a t i o n , s o p h i s t i c a t i o n , and modernisation of s e r v i c e , and u s u a l l y a t the expense of r u r a l p o p u l a t i o n s . S i m i l a r l y , any apparent c o n t r a d i c t i o n s as t o the e f f e c t i v e n e s s of t h i s system o f h e a l t h care d e l i v e r y {as was i d e n t i f i e d by r e s e a r c h i n t o the e f f e c t i v e n e s s of p r e v e n t i v e h e a l t h care s e r v i c e s ) i s r e c o n s t r u c t e d i n t h i s l i g h t . The response i s u s u a l l y one of r e o r g a n i z a t i o n and/or r e v i s i o n of e x i s t i n g s t r a t e g i e s . 78 Concomitantly, these s t r a t e g i e s o v e r r i d e the f u l l and a u t h e n t i c involvement of r u r a l , peasant communities. The M i n i s t r y of H e a l t h may encourage and r e c o g n i z e the " s e l f - h e l p " a c t i v i t i e s of r u r a l communities — s i n c e i t i s p o l i t i c a l l y expedient t o do so — but i n r e a l i t y , withdraw from any stance of n e g o t i a t i o n and co- d e t e r m i n a t i o n with r u r a l communities. To do so would d e n i g r a t e the a u t h o r i t y and power of i t s own p o s i t i o n . In p r i n c i p l e , t h e r e f o r e , open and p r o d u c t i v e communication, d i a l o g u e , and work between M i n i s t r y of H e a l t h personnel and community e l d e r s and h e a l t h workers i s d i f f i c u l t t o imagine. In summation, the c o n c e p t u a l i z e d " p r o p o s a l " f o r a n a t i o n a l CBHC programme i s : (i) t r a n s l a t e d through the symbolic idiom of bio m e d i c i n e — where Western (modern) ,. c l i n i c a l l y - b a s e d h e a l t h c a r e i s p e r c e i v e d to be a s u p e r i o r h e a l t h care s t r a t e g y — and ( i i ) f u r t h e r c o n s t r a i n e d by a b u r e a u c r a t i c o r g a n i z a t i o n that i s s t r u c t u r a l l y and o r g a n i z a t i o n a l l y top-heavy and t h e r e f o r e unnable to respond f l e x i b l y and immediately t o r u r a l - b a s e d , community-derived f e l t needs. While i t i s i d e o l o g i c a l l y i n agreement with a "development from below" p e r s p e c t i v e , i t i s o r g a n i z a t i o n a l l y i n c a p a b l e of f u r n i s h i n g the ambience t h a t would permit t h i s form of community p a r t i c i p a t i o n and involvement. And yet, attempts have been made to organize such a system o f CBHC through government-sponsored channels. 79 2.3 THE SOCIAL ORGANIZATION OF AH "EXPERIMENTAL" COMMUNITY-BASED HEALTH CARE PROGRAMME ... as experience elsewhere demonstrates, i t i s very d i f f i c u l t t o e s t a b l i s h adequate linicaqes between the f o r m a l h e a l t h s e r v i c e s and community  h e a l t h workers. T h i s d i f f i c u l t y i s compounded by the M i n i s t r y of H e a l t h ' s l a c k of e x p e r i e n c e i n t h i s a r e a . 3 6 2.3.1 F o r c i n g the I s s u e of Community-Based H e a l t h Care: The B u r e a u c r a t i c C o n s t r a i n t s As the p r e v i o u s r e c o r d of p l a n n i n g and p o l i c y events i n d i c a t e s , i t took q u i t e some time before d i s c u s s i o n s by M i n i s t r y of Health o f f i c i a l s around the t o p i c of "community-based h e a l t h c a r e " e v e n t u a l l y r e s u l t e d i n s p e c i f i c recommendations and plans f o r a n a t i o n a l programme. By t h i s time primary h e a l t h care (PHC) or CBHC was a l r e a d y a r e c o g n i z e d , implemented programme i n the a d j a c e n t c o u n t r i e s of T a n z a n i a 3 7 and the S u d a n . 3 8 The M i n i s t r y o f H e a l t h i n the Republic of Kenya, on the other hand, r e s i s t e d the f o r m u l a t i o n of s i m i l a r p l a n s . Even though s t a t i s t i c a l s t u d i e s i n d i c a t e d t h a t a mere 15-3035 of the population, u t i l i z e d the e x i s t i n g h e a l t h s e r v i c e s , 3 9 the response by M i n i s t r y of Health o f f i c i a l s was one c h a r a c t e r i s t i c of t h e i r p r o f e s s i o n a l (biomedical) o r i e n t a t i o n . T h e i r r e a c t i o n to ; r e p o r t s of u n d e r - u t i l i z a t i o n of h e a l t h care s e r v i c e s was t q plan f o r : (i) i n c r e a s i n g the r a t e of expansion and c o n s t r u c t i o n of r u r a l h e a l t h f a c i l i t i e s — namely, h e a l t h c e n t r e s , h e a l t h s u b - c e n t r e s , and d i s p e n s a r i e s ; 4 0 £ii) a c o n s i d e r a t i o n of an " i n t e g r a t i o n " of s e r v i c e s a p p r o a c h ; 4 1 80 and ( i i i ) the o r g a n i z a t i o n of a r e - t r a i n i n g programme f o r e x i s t i n g cadres of h e a l t h workers to a c t as "community animateurs."* 2 A d d i t i o n a l l y , the new cadre of Familx MSSiife F i e l d Educators (FHFEs) was c r e a t e d . 4 3 Each one of these approaches accentuates the o p p o s i t i o n between "government" and "community" — or the " f o r m a l " and " i n f o r m a l " h e a l t h s e c t o r s . Furthermore, these d i f f e r e n c e s are c o n c r e t i z e d and s u s t a i n e d by M i n i s t r y of H e a l t h o f f i c i a l s i n the language of " t r a d i t i o n a l " and "modern," "urban 1! and " r u r a l , " and " n a t i o n " and "community" comparisons. , The e x p e r i e n c e of r u r a l , peasant communities, f o r example, evokes images of t r a d i t i o n a l medicine, t r a d i t i o n a l b i r t h a t t e n d a n t s (TBAs) , h e r b a l i s t s , d i v i n e r s , and d i s e a s e s caused by w i t c h c r a f t and s o r c e r y . From the p e r s p e c t i v e of Western^trained (Kenyan) p h y s i c i a n s , t h i s world of misguided and m i s - d i r e c t e d a c t i v i t y must give way to the modernizing i n f l u e n c e of an e f f e c t i v e , c l i n i c a l l y - b a s e d medicine. . T h i s development i s a l s o perceived t o be b e n e f i c i a l f o r the n a t i o n a t l a r g e . I t would r e q u i r e a dramatic change i n p e r s p e c t i v e , t h e r e f o r e , f o r o f f i c i a l s of the M i n i s t r y of Health to imagine and then to c r e a t e " p r o f e s s i o n a l " l i n k s with r u r a l communities. The purpose of t h i s s e c t i o n i s to review the a c t u a l , documented attempts to f l e s h - o u t the o r g a n i z a t i o n a l s t r u c t u r e of a n a t i o n a l CBHC programme (see F i g u r e 5 ) . Before doing so, however, I ex p l o r e the t r a n s i t i o n a l phase between (i) a purely c l i n i c - b a s e d approach and ( i i ) an F i g u r e 5. A d m i n i s t r a t i v e O r g a n i z a t i o n Proposed by the M i n i s t r y o f H e a l t h i n Kenya f o r a N a t i o n a l CBHC Programme Resource A d v i s o r y Group — -[ A f r i c a n M e d i c a l and Research F o u n d a t i o n (AMREF), U n i t e d N a t i o n s I n t e r n a t i o n a l C h i l d r e n ' s Emergency Fund (UNICEF), and U n i v e r s i t y o f N a i r o b i - Department o f Community H e a l t h ] D i s t r i c t Development Committee [ H e a l t h Sub- — Committee: Community Development A s s i s t a n t s and A g r i c u l t u r a l E x t e n s i o n Workers] M i n i s t r y - o f H e a l t h - He a d q u a r t e r s D i r e c t o r o f Me d i c a l S e r v i c e s S e n i o r Deputy D i r e c t o r o f M e d i c a l S e r v i c e s [ A l s o D i r e c t o r o f N a t i o n a l F a m i l y W e l f a r e Centre and Rural H e a l t h Development P r o j e c t ] Rural H e a l t h Development P r o j e c t [Community-Based H e a l t h Care Development U n i t ] P r o v i n c i a l M e d i c a l O f f i c e r o f H e a l t h D i s t r i c t M e d i c a l O f f i c e r o f H e a l t h D i s t r i c t Rural H e a l t h Management Team [Community-Based H e a l t h Care Team: Community Nurse, F a m i l y H e a l t h F i e l d E d u c a t o r , P u b l i c H e a l t h T e c h n i c i a n s , H e a l t h E d u c a t o r s ] Community H e a l t h Committee COMMUNITY HEALTH WORKERS . C e n t r a l ' C e n t r a l " P r o v i n c i a l " I n t e r m e d i a t e " 1 D i s t r i c t [ D i v i d e d i n t o : D i v i s i o n s , L o c a t i o n s , and S u b - l o c a t i o n s ] " I n t e r m e d i a t e " R u r a l " P e r i p h e r a l " 82 "experimental" approach combining c l i n i c - b a s e d and community-based programmes. These were the st e p s which were taken by the M i n i s t r y of Health to r e c t i f y the problem of u n d e r - u t i l i z a t i o n of p r e v e n t i v e h e a l t h care s e r v i c e s i n the r u r a l areas. The f o l l o w i n g programme statements by M i n i s t r y o f Health o f f i c i a l s r e i t e r a t e s , with f i r m n e s s and t e n a c i t y , i t s p o s i t i o n r e g a r d i n g the v i r t u e s of the c l i n i c a l model. 2.3.1.1 On " I n t e g r a t i o n " Seven years a f t e r the i n i t i a l plans f o r the c o n s t r u c t i o n of s i x S u r a l H e a l t h T r a i n i n g Centres were made, an e v a l u a t i o n of t h e i r e f f e c t i v e n e s s was org a n i z e d by the R u r a l H e a l t h Development P r o j e c t (RHDP) of the M i n i s t r y of H e a l t h . The r e s u l t s were pre s e n t e d i n the A E E r a i s a l and P r o j e c t S.ec_uest Report. T h i s r e p o r t emphasized the n e c e s s i t y f o r an i n t e g r a t i o n of s e r v i c e s provided i n r u r a l a r e a s : when we t a l k of " i n t e g r a t i o n " we r e f e r both t o the c r e a t i o n of a s t r o n g and t a n g i b l e , i n t e r - r e l a t i o n s h i p , both f u n c t i o n a l l y and i d e o l o g i c a l l y , between the v a r i o u s d i v i s i o n s w i t h i n the M i n i s t r y of Health, as w e l l as the establishment of i n t e r - o r g a n i z a t i o n a l procedures i n v o l v i n g problem f o r m u l a t i o n , a c t i o n p l a n n i n g and implementation p o l i c i e s w i t h i n the c o n t e x t of r u r a l development.** The M i n i s t r y of H e a l t h r e c o g n i z e d the o p e r a t i o n a l and f u n c t i o n a l problems r e s u l t i n g from a fragmented and h i g h l y s p e c i a l i z e d approach t o h e a l t h c a r e d e l i v e r y . &n attempt t q c o o r d i n a t e a merging o f c u r a t i v e , d i s e a s e p r e v e n t i v e , and h e a l t h promotion a c t i v i t i e s was p e r c e i v e d to be of b e n e f i t 83 to the consumer of h e a l t h care s e r v i c e s . A subsequent r e p o r t on "Kenya's R u r a l Health S e r v i c e s " re-emphasized the p l a n f o r i n t e g r a t i o n of s e r v i c e s : In the new MCH/FP (Maternal C h i l d H e a l t h / F a m i l y Planning) programme care arrangements, the s e r v i c e s f o r mothers and c h i l d r e n w i l l be on a d a i l y b a s i s and i n t e g r a t e d . , A suger-market arrangement f o r a n t e - n a t a l , p o s t - n a t a l , m a t e r n i t y , c h i l d w e l f a r e , f a m i l y planning and h e a l t h education s e r v i c e s , i s expected to ensure more e f f e c t i v e h e a l t h c a r e coverage f o r f a m i l i e s i n general and f o r mothers and c h i l d r e n i n p a r t i c u l a r . 4 5 T h i s q u o t a t i o n evokes an image of r u r a l h e a l t h s e r v i c e s t h a t i s a t t r a c t i v e , modern, and e f f i c i e n t . No r e f e r e n c e i s given to the f a c t t h a t r u r a l p o p u l a t i o n s may not p e r c e i v e or understand the b e n e f i t s of these s e r v i c e s i n the same way. 2.3.1.2 On "Community P a r t i c i p a t i o n " At the same time t h a t M i n i s t r y of Health o f f i c i a l s were. r e o r g a n i z i n g the o p e r a t i o n of r u r a l h e a l t h care s e r v i c e s i n an i n t e g r a t e d f a s h i o n , e f f o r t s were made to r e - t r a i n . e x i s t i n g cadres of h e a l t h workers. .. The message f o r h e a l t h workers was t h a t h e a l t h i n t e r v e n t i o n tasks (eg., Maternal C h i l d Health/Family Planning) would be b e t t e r r e c e i v e d i f they educated and informed the members of communities to p a r t i c i p a t e i n t h e i r own h e a l t h c a r e : The r o l e of community p a r t i c i p a t i o n as a p a r t n e r i n the g e n e r a l e f f o r t of improving the h e a l t h s t a t u s of f a m i l i e s has not been f u l l y a p p r e c i a t e d by the m a j o r i t y of our h e a l t h workers i n our i n s t i t u t i o n s . T h i s i s one programme whose su c c e s s very much depends on f u l l community p a r t i c i p a t i o n i n the v a r i o u s h e a l t h i n t e r v e n t i o n t a s k s which are geared towards improvement of the h e a l t h of 84 i n d i v i d u a l f a m i l i e s and community. Again here, a r e o r i e n t a t i o n programme i s necessary to i n c u l c a t e i n t o the minds of our h e a l t h workers the need f o r them to a c t i v e l y seek community p a r t i c i p a t i o n f o r t h e i r h e a l t h c a r e . 4 6 T h i s q u o t a t i o n by the S e n i o r Deputy D i r e c t o r of Medical S e r v i c e s [S.D.D.M.S., E u r a l Health) i n the M i n i s t r y of H e a l t h , c a l l s f o r a more communicative, i n f l u e n t i a l , and s o p h i s t i c a t e d h e a l t h c a r e worker. The h e a l t h c a r e worker [employed by the Government) i s i n s t r u c t e d t o be knowledgeable and p r o f e s s i o n a l i n matters r e l a t i n g t o h e a l t h c a r e s e r v i c e s . He i s a l s o expected to i n t e r v e n e i n the l i v e s of r u r a l peasants seemingly f o r t h e i r u l t i m a t e good. The i m p l i c a t i o n of t h i s statement i s t h a t " i n d i v i d u a l f a m i l y and community" members ar e impassive and uninformed and subsequently need to be educated i n "community p a r t i c i p a t i o n ; " i . e . , to u t i l i z e the a v a i l a b l e c l i n i c a l s e r v i c e s . while an exchange and d i a l o g u e of i d e a s between community members and Government h e a l t h care workers would be a p p r e c i a t e d , the nature of these comments suggests an a s c r i b e d s u p e r i o r i t y t o the h e a l t h care worker. , D i r e c t i v e s r e g a r d i n g h e a l t h c a r e behaviour a r e imposed and not d i s c u s s e d by the Government h e a l t h care worker i n the c l i e n t p o p u l a t i o n . 2.3.1.3 The "Family H e a l t h F i e l d Educator" (FHFE) Programme The Family H e a l t h F i e l d Educator (FHFE) programme was c r e a t e d by the M i n i s t r y of Health to form a " l i n k " between 85 r u r a l h e a l t h f a c i l i t i e s and the r u r a l communities i n need of these s e r v i c e s . By the end of 1978 there were 457 FHFEs deployed to the P r o v i n c e s 4 7 and i f i s estimated t h a t by 1983 th e r e w i l l be 1,334 FHFEs employed by the Government. 4 8 These workers are t r a i n e d by the MaSignal Family Welfare Centre [a d i v i s i o n of R u r a l Health S e r v i c e s , M i n i s t r y of Health) t o encourage women i n the r u r a l areas to use the a v a i l a b l e Maternal C h i l d Health / Family P l a n n i n g (HCH/FP) s e r v i c e s . They are intended — as t h e i r p r o f e s s i o n a l t i t l e i n d i c a t e s - - t o be educators and mot i v a t o r s i n d i s e a s e p r e v e n t i o n , h e a l t h promotion, and f a m i l y p l a n n i n g . The t a r g e t p o p u l a t i o n f o r these Family H e a l t h F i e l d Educators (FHFEs) are women of c h i l d bearing age and c h i l d r e n under f i v e years of age. Pa r t and p a r c e l of the FHFE's job d e s c r i p t i o n i s t o work, not only at the c l i n i c , but p r i m a r i l y i n the community. 4 9 The FHFE i s expected t o generate p u b l i c support f o r the Maternal C h i l d Health and Family Planning programme, and t o follow-up and make reassurance v i s i t s t o mothers and a c c e p t o r s of Fam i l y Planning methods. 5 0 Most of these a c t i v i t i e s i n v o l v i n g education and mo t i v a t i o n are t o be c a r r i e d out i n h o m e - v i s i t i n g i n the community. But i n f a c t , as one r e p o r t suggests: the F i e l d Educators may spend too much time i n the c l i n i c s and too l i t t l e time i n the communities, thus l i m i t i n g t h e i r c o n t a c t s with those women who probably would n o t atte n d the c l i n i c s f o r any k i n d of s e r v i c e without a d d i t i o n a l i n f o r m a t i o n and m o t i v a t i o n . 5 1 86 An e v a l u a t i o n of the work load of Family H e a l t h F i e l d Educators (FHFEs) confirmed these s u s p i c i o n s . Only a t h i r d o f the time i s spent by the FHFEs i n the community, the remaining time i s spent t r a v e i l i n g or a t the c l i n i c . S 2 Furthermore, while at the c l i n i c , the Family H e a l t h F i e l d Educator (FHFE) i s i n v o l v e d i n e v e r y t h i n g but h e a l t h education and h e a l t h promotion. She spends time t a k i n g blood p r e s s u r e , weighing mothers and c h i l d r e n , g i v i n g immunizations, g i v i n g c a r d s to c l i e n t s , g i v i n g out medicine, t a k i n g temperature, s t e r i l i z i n g equipment, examining c l i e n t s , and c l e a n i n g the c l i n i c . 5 3 A year a f t e r t h i s e v a l u a t i o n r e p o r t was p u b l i s h e d , i t was s t i l l the hope of H i u i s t r y of Health o f f i c i a l s t h a t the s t y l e of t r a i n i n g , r ecruitment and deployment of the FHFE (Family H e a l t h F i e l d Educator) w i l l provide an i n d i v i d u a l who i s both a c c e p t a b l e and a c c e s s i b l e t o the community f o r purposes of e n l i s t i n g t o t a l community p a r t i c i p a t i o n i n a c t i v i t i e s r e l a t e d to f a m i l y h e a l t h . 5 * 2.3.2 P r o p o s a l f o r the O r g a n i z a t i o n of a N a t i o n a l "Community-Based He a l t h Care" Programme The apparent b u r e a u c r a t i c c o n s t r a i n t s w i t h i n the M i n i s t r y of Health due to i t s c l i n i c a l o r i e n t a t i o n p e r m i t t e d me to make t h i s i n t e r p r e t a t i o n : i n i t s attempt to address the "problem" of r u r a l h e a l t h s e r v i c e s (namely,. u n d e r - u t i l i z a t i o n of p r e v e n t i v e s e r v i c e s ) , the M i n i s t r y simply re-^worked and r e - o r g a n i z e d e x i s t i n g "management" s t r a t e g i e s . Emphasis was p l a c e d on the i n t e g r a t i o n of s e r v i c e s so as to i n c r e a s e the a t t r a c t i v e n e s s o f s e r v i c e s 87; o f f e r e d . kt the same time, the p o s i t i o n o f Family Health, F i e l d Educator (FHFE) was cr e a t e d to " h o p e f u l l y " s t i m u l a t e a p o s i t i v e response from r u r a l p o p u l a t i o n s t o Maternal and C h i l d Health and Family Planning (MCH/FP) s e r v i c e s . The experience with FHFEs i n d i c a t e d , however, t h a t these h e a l t h workers were more co m f o r t a b l y engaged i n c l i n i c a l l y - b a s e d a c t i v i t i e s than i n the proposed a c t i v i t i e s o f "educator" promoting community p a r t i c i p a t i o n i n the community. Indeed, the meaning of "community p a r t i c i p a t i o n " i m p l i c i t i n these r e - o r g a n i z e d h e a l t h c a r e ventures i s th a t a f a v o u r a b l e response to c l i n i c a l l y - b a s e d h e a l t h care s e r v i c e s i s e l i c i t e d . In other words, t o a d m i n i s t r a t i v e o f f i c i a l s w i t h i n the M i n i s t r y of Hea l t h , "community p a r t i c i p a t i o n " means an e f f i c i e n t u t i l i z a t i o n o f c l i n i c - b a s e d s e r v i c e s by community members., T h i s s t a r t l i n g d i f f e r e n c e i n the meaning of "community p a r t i c i p a t i o n " — between the view o f M i n i s t r y a d m i n i s t r a t o r s and proponents of s e l f - d i r e c t e d CBHC programmes — h i g h l i g h t s the e p i s t e m o l o g i c a l bent of the M i n i s t r y of H e a l t h . C l e a r l y , the axiomatic p r i n c i p l e of M i n i s t r y of He a l t h p o l i c y i s t o promote c l i n i c a l l y - b a s e d systems of h e a l t h c a r e ; t h i s t a c t i c i s v a l i d a t e d by Western, bi o m e d i c a l p r i n c i p l e s , and expresses the p r o g r e s s i v e and modernist o r i e n t a t i o n o f M i n i s t r y o f f i c i a l s . 2.3.2.1 The S h i f t i n g Paradigm 88 With the r e a l i z a t i o n t h a t i t would be economically i m p o s s i b l e t o s u s t a i n c u r r e n t trends emphasizing c u r a t i v e ( c l i n i c - b a s e d ) s e r v i c e s , the M i n i s t r y o f H e a l t h was g r a d u a l l y compelled to r e - i n t e r p r e t the n o t i o n of "community involvement." Rather than i n t e r p r e t i n g t h i s " p a r t i c i p a t i o n " as an index of r e s p o n s e / u t i l i z a t i o n to the Government's a l l o c a t i o n of h e a l t h c a r e s e r v i c e s , i t g r a d u a l l y came to r e c o g n i z e the s u i g e n e r i s nature of needs and p r i o r i t i e s generated by the members of r u r a l communities. I n i t i a l attempts to adumbrate the rough o u t l i n e s of such involvement: was the r e c o g n i t i o n of d i f f e r e n c e s i n e c o l o g i c a l c o n d i t i o n s i n the r u r a l areas. To c l a r i f y t h i s f a c t o r , the R e p u b l i c of Kenya was d i v i d e d i n t o f o u r .Rural Health S e r v i c e Delivery. &2aSS^  the h i g h l a n d zone, the marginal zone, the hot/humid zone, and the s e m i - a r i d z o n e . s 5 T h i s mapping procedure r a i s e d the i s s u e of a v a r i a t i o n i n s e r v i c e approach r e l a t i v e to the environmental c o n d i t i o n s . Subsequently, i t was r e c o g n i z e d t h a t d i f f e r e n c e s i n the s o c i a l and c u l t u r a l environment were necessary c o n s i d e r a t i o n s . Migue and Ndungu i d e n t i f y these problems i n t h e i r e x c e l l e n t a r t i c l e on "Rural Health Management - the Kenyan Ex p e r i e n c e : " S o c i a l l y and c u l t u r a l l y , the people e x h i b i t d i f f e r e n t c h a r a c t e r i s t i c s and i t w i l l be u n r e a l i s t i c t o b e l i e v e that one h e a l t h s e r v i c e d e l i v e r y system can adapt to these d i v e r s e c o n d i t i o n s . I t i s t h e r e f o r e necessary t o develop a s e r v i c e s t r u c t u r e which takes cognizance of these c o n d i t i o n s and i t i s i m p e r a t i v e that p l a n s f o r i n v o l v i n g the community more e x p l i c i t l y i n h e a l t h c a r e , must r e c o g n i z e p a r t i c u l a r l y s o c i a l s t r u c t u r e s and v a l u e s . s 6 89 With the r e a l i z a t i o n t h a t v a r i a t i o n i n s o c i a l , c u l t u r a l , and environmental c o n d i t i o n s i s a p r e v a i l i n g c h a r a c t e r i s t i c of the r u r a l areas s e r v i c e d by the M i n i s t r y o f H e a l t h , the problem remained as t o how to work with t h i s s i t u a t i o n i n the o r g a n i z a t i o n and implementation o f CBHC. The D i r e c t o r o f the N a t i o n a l P i l o t P r o j e c t i n Community-Based Health Care i n Western Kenya i d e n t i f i e s t h i s p r o c e s s 5 7 as being the c r i t i c a l i s s u e . She c a l l s f o r the s y s t e m a t i c study of how community p a r t i c i p a t i o n i n h e a l t h care can be i n i t i a t e d and e s t a b l i s h e d i n the Kenyan s e t t i n g . 5 8 In the f o l l o w i n g s e c t i o n , a d e s c r i p t i o n of the M i n i s t r y of Hea l t h ' s o r g a n i z a t i o n a l scheme f o r a n a t i o n a l CBHC programme i s g i v e n . The i n f o r m a t i o n used to c o n s t r u c t t h i s scheme i s taken from the few p r e l i m i n a r y r e p o r t s of the P i l o t P r o j e c t on CBHC i n Western Kenya (sponsored by the M i n i s t r y of H e a l t h and UNICEF) as w e l l as from M i n i s t r y of H e a l t h p r o p o s a l documents on the s u b j e c t . 2.3.2.2 Proposed C e n t r a l and D i s t r i c t L e v e l O r g a n i z a t i o n The l a t e s t 4 p p r a i s a l B e p o r t s 9 of the I n t e g r a t e d R u r a l H e a l t h and Family, P l a n n i n g Programme (IRH/FP) propounds t h i s c e n t r a l and d i s t r i c t l e v e l o r g a n i z a t i o n f o r the n a t i o n a l CBHC programme. at the c e n t r a l l e v e l , t h e r e i s planned a Community-Based Health Care Development Un i t (see F i g u r e 5). T h i s Development U n i t would help t o formulate p o l i c y , promote community-based he a l t h c a r e schemes, review and approve p r o p o s a l s f o r schemes t o be funded from p r o j e c t funds, s e t 90 g u i d e l i n e s f o r CHW (Community He a l t h Worker) s t i p e n d s , t r a i n s t a f f o f d i s t r i c t R u r a l H e a l t h Management Teams i n community-based h e a l t h c a r e , and monitor and e v a l u a t e schemes. 6 0 T h i s Unit would be supported with t e c h n i c a l a s s i s t a n c e by a Be,source A d v i s o r y Group composed of r e p r e s e n t a t i v e s from the Department of Community Health (the U n i v e r s i t y of N a i r o b i ) , UNICEF (United Nations I n t e r n a t i o n a l C h i l d r e n ' s Emergency Fund), and AMREF (the A f r i c a n Medical and Research Foundation) . 6 » At the d i s t r i c t l e v e l , the Health Sub-Committee of the D i s t r i c t Development Committee would work c l o s e l y with the d i s t r i c t R ural H e a l t h Management Tea.m i n promoting CBHC schemes. 6 2 T h e i r f u n c t i o n would be to a s s i s t communities i n the establishment of Community Health Committees (see 2.3.2.3.) who would be given the r e s p o n s i b i l i t y o f s e l e c t i n g , paying, and s u p e r v i s i n g t h e i r Community Health Workers (CHWs). Furthermore, the D i s t r i c t Team would oversee the work of the Community Health Committees and a s s i s t them i n the s u b m i t t i n g of p r o p o s a l s f o r funding t o the M i n i s t r y of He a l t h ' s Development U n i t . The composition of the D i s t r i c t l e v e l "Community-Based He a l t h Care Team" i n the N a t i o n a l P i l o t P r o j e c t i n Community-Bashed Health Care brought together the f o l l o w i n g h e a l t h care p e r s o n n e l : a Community Nurse (the Team Leader), P u b l i c Health T e c h n i c i a n s , Family H e a l t h F i e l d Educators (FHFEs), a Community Development A s s i s t a n t , an A g r i c u l t u r a l E x t e n s i o n Worker, and H e a l t h E d u c a t o r s . 6 3 Once a g a i n , t h e i r f u n c t i o n 91 was to a s s i s t communities i n the establishment of community support s t r u c t u r e s . T h i s complex a d m i n i s t r a t i v e o r g a n i z a t i o n of CBHC a c t i v i t i e s a t the C e n t r a l and D i s t r i c t l e v e l s i s r e f e r r e d to as t h e necessary " s u p p o r t i v e c e n t r a l m a c h i n e r y " 6 4 o u t s i d e of the community. There a r e two g e n e r a l f u n c t i o n s a t t r i b u t e d to t h i s h e a l t h care i n f r a s t r u c t u r e as i t a f f e c t s the i n i t i a t i o n and implementation of CBHC a c t i v i t i e s . F i r s t l y , , i t f u l f i l l s the f u n c t i o n of " p a r t i c i p a t o r y m a c h i n e r y . " 6 5 In, o t h e r words, the d i s t r i c t l e v e l teams a c t as f a c i l i t a t o r s f o r CBHC. These teams are the "communication t o o l " 6 6 i n the promotion o f "community support s t r u c t u r e s " f o r CBHC a c t i v i t i e s and a s s i s t i n the; i ) the process o f d e f i n i n g and d e l i n e a t i n g the u n i t of community — the f u n c t i o n a l base f o r com m u n i t y - p a r t i c i p a t o r y activities.„ i i ) the e s t a b l i s h m e n t of Community Health Committees. i i i ) the es t a b l i s h m e n t of Community Accounts., i v ) the s e l e c t i o n o f Community Health W o r k e r s . 6 7 The second f u n c t i o n o f the h e a l t h care system i n f r a s t r u c t u r e — as i t a f f e c t s a n a t i o n a l Government programme on CBHC — i s that i t a c t s as the necessary support s t r u c t u r e f o r me d i c a l problems too d i f f i c u l t f o r the Community H e a l t h Worker (CHW). T h i s important f u n c t i o n s a t i s f i e s a fundamental p r i n c i p l e i n the o r g a n i z a t i o n of CBHC; i . e . , t h a t an e f f e c t i v e CBHC programme r e g u i r e s the c l i n i c a l ( c u r a t i v e ) support of the h e a l t h c a r e s e r v i c e 92 i n f r a s t r u c t u r e . For example, when a Community Health Worker (CHW) i s confronted with a medical problem t h a t i s beyond h i s / h e r e x p e r t i s e , the CHW has the recourse of r e f e r r i n g the p a t i e n t to the next l e v e l i n the h e a l t h care system ( i . e . , the dispensary, h e a l t h c e n t r e s , or D i s t r i c t H o s p i t a l ) . Once a g a i n , t h i s c onfirms the importance of a "two pronged a p p r o a c h " 6 8 t h a t the M i n i s t r y of Health proposes to implement: " c l i n i c s " and "community-based h e a l t h c a r e . " 2.3.2.3 Proposed O r g a n i z a t i o n a t the "Community" L e v e l The M i n i s t r y of H e a l t h documents on the proposed CBHC programme i d e n t i f i e s the problem of d e f i n i n g and d e l i n e a t i n g the f u n c t i o n a l base f o r " community-participatory" a c t i v i t i e s as b e i n g an important c o n s i d e r a t i o n . As the D i r e c t o r of the N a t i o n a l P i l o t P r o j e c t i n Community-Based He a l t h Care suggests, t h e r e are a number of o r g a n i z a t i o n a l s t r u c t u r e s to be c o n s i d e r e d : " i n f o r m a l formal s t r u c t u r e s , " " v i l l a g e , " and "community." 6 9 The view of the D i r e c t o r i s t h a t the s o - c a l l e d " i n f o r m a l f o r m a l s t r u c t u r e s " are a c t u a l l y the t r a d i t i o n a l o r g a n i z a t i o n s composed of clans, and lingaass* These o r g a n i z a t i o n a l bonds, however, have been s e r i o u s l y a f f e c t e d by t r e n d s towards modernization. With the m i g r a t i o n of persons to the urban areas f o r work, along with r e s e t t l e m e n t schemes, land purchases, and an i n c r e a s e i n the l e v e l of m o b i l i t y , the importance of c l a n and l i n e a g e groupings as an o r g a n i z a t i o n a l p r i n c i p l e has d i m i n i s h e d . 93 For these reasons, she suggested t h a t these t r a d i t i o n a l s t r u c t u r e s may not be s u i t a b l e as a f u n c t i o n a l base f o r CBHC a c t i v i t i e s . F or s i m i l a r reasons, t h i s D i r e c t o r b e l i e v e s t h a t the u n i t o f " v i l l a g e " i s an inadeguate f u n c t i o n a l base f o r CBHC. The term " v i l l a g e " i t s e l f i s a s s o c i a t e d "with groupings w i t h i n r e l i g i o u s d e n o m i n a t i o n s . " 7 0 In some i n s t a n c e s , however, a " v i l l a g e " i s i d e n t i f i e d with a c l u s t e r of homesteads i n an e a s i l y i d e n t i f i a b l e a r e a (perhaps along a r i d g e ) and composed of households o f r e l a t e d p e r s o n s . 7 * A " v i l l a g e " i s u s u a l l y a s m a l l e r u n i t w i t h i n the l a r g e r , g e o g r a p h i c a l u n i t of "community." In terms of the exp e r i e n c e of the N a t i o n a l P i l o t P r o j e c t , "community" appears t o be the p r e f e r r e d u n i t f o r the o r g a n i z a t i o n of CBHC a c t i v i t i e s . 7 2 I t i s g e o g r a p h i c a l l y d e l i m i t e d and i n f o r m a l l y r e c o g n i z e d t o be so by r e s i d e n t s i n the area. In most c a s e s , i t f o l l o w s a d m i n i s t r a t i v e boundaries (for example i n t o l o c a t i o n s and s u b - I o c a t i o n s ) 7 3 and i s headed by a l e a d e r f o r m a l l y r e c o g n i z e d by the government. The community l e a d e r i n the P i l o t P r o j e c t area i n Western Kenya i s the l i g u r u ( p i . maguru). 7 4 He i s the person who s e t t l e s d i s p u t e s i n the area, c a r r i e s out b a s i c f u n c t i o n s , and o r g a n i z e s people f o r " s e l f - h e l p " and other p u b l i c a c t i v i t i e s . 7 5 Each area i n the coun t r y i s d i f f e r e n t , however, and may experience "community" f o r varying p a r t i c i p a t o r y reasons,: 94 I t may i n v o l v e persons who go to the same market, draw water at t h e same s p r i n g , or who recognize and share the same l e a d e r . Whatever the reason, the people know what i t i s t h a t makes them p a r t i c i p a n t members i n a c e r t a i n community. Community, t h e r e f o r e , i s an experience of belonging and of membership with persons i n a s p e c i f i c a r e a . One r e p q r t suggests t h a t i t c o n s t i t u t e s 100-400 household u n i t s 7 6 whose members can be m o b i l i z e d to engage i n a c t i v i t i e s t h a t w i l l b e n e f i t the whole. For the purpose of implementing CBHC programmes, the M i n i s t r y of Health recommends that the D i s t r i c t l e v e l teams i d e n t i f y pre-formed s o c i a l groups w i t h i n the community. These " t a r g e t g r o u p s " 7 7 may be church groups, c o o p e r a t i v e s , women's groups (in K i s w a h i l i , maendeleo ya wanawake), s c h o o l s , or other development groups i n the community which c o u l d act as a s p r i n g b o a r d f o r the programme. As mentioned p r e v i o u s l y , Community H e a l t h Committees would be o r g a n i z e d to a c t as the f a c i l i t a t i n g s t r u c t u r e w i t h i n the community f o r CBHC. These Community Health Committees c o u l d be an outgrowth or e x t e n s i o n of e x i s t i n g development groups such as church groups, women's groups, e t c . — and would be composed of approximately ten members. Each member would have a s p e c i f i c f u n c t i o n w i t h i n the Committee on b e h a l f of the community: s p r i n g p r o t e c t i o n , improving s a n i t a t i o n , food a v a i l a b i l i t y , c h o l e r a outbreaks, immunizations, and so o n . 7 8 Furthermore, the members of the Community Health 95 Committee would be r e s p o n s i b l e f o r the s e l e c t i o n , support,, and s u p e r v i s i o n of Community Health Workers (CHWs). 2.3.2.4 The Community He a l t h Workers (CHWs) The Community H e a l t h Worker (CHW) s e l e c t e d by the Community Health Committee i s t o be a part-time employee of the communities they s e r v e . Unlike the F a m i l y g e a l t h Ejeld, Educator (FHFE) who i s a f u l l - t i m e employee of the M i n i s t r y o f Health and prone t o work out of the c l i n i c > the Community He a l t h Worker (CHW) i s s i m i l a r l y t r a i n e d but would be: r e q u i r e d t o work out of h i s / h e r home. The m a j o r i t y of CHWs are expected to be women even though there are no r e s t r i c t i o n s a g a i n s t men becoming Community H e a l t h Workers. In the n a t i o n a l P i l o t P r o j e c t i n CBHC, f o r example, the c r i t e r i a f o r the s e l e c t i o n of Community H e a l t h Workers (CHWs) i s that they be " l i t e r a t e i n the l o c a l language,. mature l a d i e s t h i r t y y e ars or above with c h i l d r e n , and a person with a good s p i r i t . " 7 9 The t a s k s t o be performed by the Community H e a l t h Worker (CHW) are d e f i n e d as f o l l o w s : Although the d u t i e s of CHWs would depend t o some extent on the l o c a l h e a l t h s i t u a t i o n , a l l would be expected t o undertake the treatment of common ail m e n t s , i n c l u d i n g o r a l r e h y d r a t i o n , h e a l t h education, f a m i l y p l a n n i n g c o u n s e l l i n g , m o t i v a t i o n and c l i e n t f o l l o w - u p , the a d m i n i s t r a t i o n of simple v a c c i n e s , and t o take p a r t i n campaigns a g a i n s t communicable d i s e a s e s . 8 0 fiemuneration f o r t he s e r v i c e s p r o v i d e d by the Community H e a l t h Worker £CHW) i s l e f t to the communities themselves. Other than t h a t , the M i n i s t r y of Health has o f f e r e d only 96 g e n e r a l g u i d e l i n e s . In the N a t i o n a l P i l o t P r o j e c t i n CBHC (sponsored by the M i n i s t r y of Health and ONICEF), i t i s recommended that a Community Account be e s t a b l i s h e d i n each community., To begin the remunerative p r o c e s s , each household i n the community i s expected to make a d e p o s i t of 10/= ( s h i l l i n g s ) . . Subsequent d e p o s i t s are made i n t o the Community Account each time t h a t a person r e c e i v e s some form of c u r a t i v e s e r v i c e from t h e i r CHB — 3/= ( s h i l l i n g s ) from an a d u l t and 1/= [ s h i l l i n g ) from a c h i l d . 8 1 The Community H e a l t h Horkers (CHHs) are p a i d 50/= ( s h i l l i n g s ) out of t h i s , Community Account once a month f o r s e r v i c e s rendered. They work approximately t h r e e days per week i n t h e i r communities. 2.3.3 D i s c u s s i o n of the M i n i s t r y of Health*,s O r g a n i z a t i o n a l Scheme f o r Community-Based Health Cage "(CBHC)" The preceding d i s c u s s i o n focused on the moment of " o r g a n i z a t i o n " i n the process of c o n s t r u c t i n g a n a t i o n a l CBHC programme. The t h r e e moments i d e n t i f i e d i n the process are c o n c e p t u a l i z a t i o n , o r g a n i z a t i o n , and management. In t h i s s e c t i o n , I d i s c u s s some of the i m p l i c a t i o n s of the proposed o r g a n i z a t i o n a l c o n s t r u c t i o n by the M i n i s t r y of H e a l t h f o r CBHC. With the s u g g e s t i o n t h a t a "two pronged approach" was needed i n the d e l i v e r y of r u r a l h e a l t h c a r e s e r v i c e s ( " c l i n i c s and community-based h e a l t h c a r e " ) , t h e r e emerged a n o t i c e a b l e s h i f t i n r u r a l h e a l t h care s t r a t e g y . I n i t i a l l y * . 9 7 the M i n i s t r y of H e a l t h invoked "community p a r t i c i p a t i o n " through a r e - o r g a n i z a t i o n of the r u r a l h e a l t h c a r e s e r v i c e i n f r a s t r u c t u r e . I t planned f o r the " i n t e g r a t i o n " of h e a l t h c a r e s e r v i c e s , a " r e - o r i e n t a t i o n " programme f o r h e a l t h workers, and the c r e a t i o n of Family Health F i e l d Educators (FHFEs). These changes were i n t e r p r e t e d as a method expected t o i n c r e a s e the e f f e c t i v e u t i l i z a t i o n of r u r a l h e a l t h care s e r v i c e s by the community — the a c t u a l meaning, of "community p a r t i c i p a t i o n " w i t h i n the M i n i s t r y of He a l t h . When M i n i s t r y of H e a l t h p o l i c y began to emphasize the need f o r "community p a r t i c i p a t i o n " w i t h i n the co n t e x t of CBHC, the s t r a t e g y employed by the M i n i s t r y of Health s h i f t e d from a r e - o r g a n i z a t i o n o f the h e a l t h care i n f r a s t r u c t u r e to a r e - o r g a n i z a t i o n of the community. M i n i s t r y o f Health o f f i c i a l s planned f o r the o r g a n i z a t i o n of " p a r t i c i p a t o r y machinery" to f a c i l i t a t e the c r e a t i o n of support s t r u c t u r e s w i t h i n the community. On the s u r f a c e , i t appears as i f the M i n i s t r y i s w i l l i n g t o work a l o n g s i d e communities i n the p l a n n i n g and development of CBHC programmes. I n a c t u a l f a c t , the o r g a n i z a t i o n a l s t r u c t u r e the M i n i s t r y o f Hea l t h proposes f o r CBHC extends i t s i n f l u e n c e and a u t h o r i t y from the e n v i r o n s of the c l i n i c base (where i t has complete s e r v i c e c o n t r o l ) to th a t of r u r a l communities. I t may be a p o s s i b i l i t y t h a t the M i n i s t r y of He a l t h i s not yet aware of the long-term i m p l i c a t i o n s of i t s own p o l i c i e s and procedures. Nevertheless, i t c o n t i n u e s t o 98 operate as i f h e a l t h c a r e ideas and s e r v i c e s are provided and d e l i v e r e d t o the r u r a l areas r a t h e r than c o n s t r u c t e d (through d i a l o g u e and d i s c u s s i o n ) with community members. For example, i t has c a l l e d f o r the c r e a t i o n and e s t a b l i s h m e n t of Community Health Committees w i t h i n each community. The procedure through which these committees are c r e a t e d b e l i e s any autonomous or s e l f - d i r e c t e d o r g a n i z a t i o n on the p a r t of the community members themselves. I n s t e a d , they are o r g a n i z a t i o n s t h a t are d i r e c t e d and s u p e r v i s e d i n t h e i r r e s p e c t i v e a c t i v i t i e s by the D i s t r i c t l e v e l Management teams. Th i s o r g a n i z a t i o n a l scheme poses s e r i o u s long-term problems f o r the implementation of CBHC programmes on a n a t i o n a l s c a l e . I f the M i n i s t r y of Health p e r s i s t s i n i t s c o n s t r u c t i o n of "communities" as r e e l p i e n t s / c l i e n t s i n the h e a l t h c a r e process, community members i n the r u r a l areas w i l l never assume the r o l e of a c t i v e agents i n the c r e a t i o n of CBHC. I n i t i a l l y , the implementation problem formulated by the M i n i s t r y of Health was how to f a c i l i t a t e the p rocess of "community p a r t i c i p a t i o n . " But as was mentioned, the meaning of "community p a r t i c i p a t i o n " t h a t i s communicated in. M i n i s t r y of H e a l t h documents turns t h i s problem i n t o the q u e s t i o n of how to c o n v i n c e community members of the l e g i t i m a c y o f Government h e a l t h c a r e methods. I t can be s t a t e d , t h e r e f o r e , t h a t the M i n i s t r y of H e a l t h f a i l s t o 99 a p p r e c i a t e t r a d i t i o n a l e x periences of community and the o r g a n i z a t i o n a l a b i l i t y of community members i n managing t h e i r h e a l t h c a r e needs. once agai n , t h i s r e f l e c t s and r e v e a l s the e p i s t e m o l o g i c a l rootedness of the M i n i s t r y i n the Western, b i o m e d i c a l t r a d i t i o n . I r o n i c a l l y , while upper l e v e l managers w i t h i n the M i n i s t r y of H e a l t h f i n d i t p o l i t i c a l l y expedient t o v o i c e t h e i r support f o r Harambee e f f o r t s i n the r u r a l a reas — a p r i n c i p l e which by d e f i n i t i o n s a n c t i o n s CBHC programmes — t h e i r i n d i v i d u a l p r o f e s s i o n a l i n t e r e s t s as p h y s i c i a n s causes them t o a c t u a l l y advance a c l i n i c a l , c u r a t i v e - b a s e d model f o r the d e l i v e r y of h e a l t h care s e r v i c e s . In t h i s l a t t e r emphasis, they l i n k arms with the s t r o n g e r Government focus on "development through m o d e r n i s a t i o n . " Furthermore, t h i s p a r t i c u l a r idiom o f h e a l t h care knowledge i s subsequently r e i f i e d and reproduced by the b u r e a u c r a t i c c o n s t r a i n s of the M i n i s t r y of H e a l t h . Once programmed i n a c e r t a i n way . i . e . , i n a b i o m e d i c a l f o r m a t ) , the o r g a n i z a t i o n o f the M i n i s t r y of H e a l t h seems t o expand and reproduce e x i s t i n g h e a l t h care s t r a t e g i e s a g a i n s t a l l o p p o s i t i o n and r e s i s t a n c e . The a l t e r n a t i v e of CBHC i s j u s t one example of t h i s tendency: i n s t e a d o f a p p r o p r i a t i n g the i d e a s and p r i n c i p l e s of CBHC as a r e l e v a n t c r i t i q u e of the e x i s t i n g h e a l t h care system, i t seems to wash over and transform t h i s system o f knowledge t o serve i t s own needs. Bather than r e s p e c t i n g the autonomy and freedom of 100 i n t e r e s t e d , communities i n c o n s t r u c t i n g t h e i r own s u i generics forms of CBHC — with CHHs s e l e c t e d , supported, and s u s t a i n e d by these communities — the government has transformed these programmes and t h e i r r e s p e c t i v e CHHs i n t o dependents. From an o r g a n i z a t i o n a l p o i n t o f view, t h e r e i s no d i a l e c t i c t o l e r a t e d between the government (centre) and the community (periphery).. Instead, t h e r e i s a s t r u c t u r e of u n i l a t e r a l c o n t r o l and a d m i n i s t r a t i o n . 2.4 THE MANAGEMENT OF A NATIONAL COMMUNITY-BASED HEALTH CAEE PROGRAMME I t was the e x p e c t a t i o n of the p r o j e c t t h a t i t would generate community a c t i o n f o r h e a l t h . We have seen t h a t the p r o j e c t has done t h a t but with the problem of developing a s e l f - s u s t a i n i n g mechanism. 8 2 Using the three p r o c e s s u a l moments of c o n c e p t u a l i z a t i o n , o r g a n i z a t i o n , and management, I have attempted to r e - c o n s t r u c t the M i n i s t r y of Health's p e r c e p t i o n and i n t e r p r e t a t i o n of CBHC. T h i s s e c t i o n f o c u s e s on the management phase i n the process of implementing CBHC programmes. U n f o r t u n a t e l y , t h e r e i s only b r i e f and c u r s o r y i n f o r m a t i o n on t h i s a s p e c t o f the programme. The M i n i s t r y of Health has v i r t u a l l y , no experience i n the management of CBHC programmes other than that of the N a t i o n a l P i l o t P r o j e c t i n Western Kenya. On the P i l o t P r o j e c t , t h e r e are only two r e p o r t s and one speech a v a i l a b l e , 8 3 and these have had a l i m i t e d c i r c u l a t i o n . 101 Ne v e r t h e l e s s , these r e p o r t s d e l i n e a t e the g e n e r a l f e a t u r e s of the management experience f o r the P i l o t P r o j e c t and some of the problems t h a t have r e s u l t e d . . S i n c e the experience of the P i l o t P r o j e c t has f u e l l e d the c o n t e n t s of the p r o p o s a l s made f o r a n a t i o n a l programme, i t can be surmised t h a t the problems r a i s e d w i l l s i m i l a r l y occur i n the l a r g e r government programme. To provide a rough o u t l i n e of the s t a t u s o f the N a t i o n a l P i l o t P r o j e c t i n Community-^Based Health Care, the f o l l o w i n g f i g u r e s are given. The N a t i o n a l P i l o t P r o j e c t s t a r t e d i n September, 1977 i n the D i s t r i c t s of Kakamega and Bungoma of Western K e n y a . 8 4 The l a t e s t r e p o r t on the P r o j e c t i n d i c a t e d t h at 153 h e a l t h committees were formed i n the two d i s t r i c t s 8 5 while an e a r l i e r r e p o r t suggested t h a t 163 Community H e a l t h Workers (CHWs), mostly women, were working i n the 163 c o m m u n i t i e s . 8 6 Given a p r o j e c t e d p o p u l a t i o n i n 1979 of 198,000 people f o r the th r e e l o c a t i o n s ( T i r i k i , South Kabras, and B o k o l i ) i n the two d i s t r i c t s of Kakamega and Bungoms, 8 7 t h i s p r e s e n t s a r a t i o of 1 Community He a l t h Worker (CHW) t o 1,200 people, flore CHWs w i l l : undoubtedly be. t r a i n e d , thereby l o w e r i n g the f i g u r e to the proposed r a t i o of 1 CHW t o 1,000 people, as recommended i n the a p p r a i s a l B e p o r t . 8 8 102 2.4.1 Management Problems i n the P i l o t P r o j e c t Area The problems t h a t are r e p o r t e d f o r the P r o j e c t f a l l i n t o t h r e e g e n e r a l areas of concern: [i) o r g a n i z a t i o n a l , [ i i ) ; e x p e r i e n t i a l , and [ i i i ) economic. The economic problems i n the programme are a l l u d e d t o i n Han ,gombe ,s a r t i c l e e n t i t l e d an Economic Study of the Community-Based H e a l t h Care P i .lot P r o j e c t i n Western K e n y a . 8 9 A l l other problems of an o r g a n i z a t i o n a l and e x p e r i e n t i a l nature are presented i n the P r o v i n c i a l Commissioner*s "Opening Speech at the Seminar on Community-Based Health C a r e . " 9 0 The f i r s t o r g a n i z a t i o n a l problem exposes the tenuous r e l a t i o n s h i p between community l e a d e r s and the D i s t r i c t l e v e l Health Management Teams. I n the words of the P r o v i n c i a l Commissioner: Community l e a d e r s and t h e i r c h i e f s i n each l o c a t i o n a r e not making f u l l use.of the a v a i l a b l e government e x p e r t i s e t o even more r e s u l t s [ s i c ) . For example; h e a l t h t e c h n i c i a n s f o r a d v i c e on s p r i n g p r o t e c t i o n ; p u b l i c h e a l t h o f f i c e r s f o r improving drainage on roads, e t c . ; a g r i c u l t u r e people t o give a d v i c e ; and c o - o r d i n a t i o n with the M i n i s t r y of Water Development, , I f community l e a d e r s h i p t a k e s on t h i s , a l o t more c o u l d be a c h i e v e d . ? 1 T h i s statement i d e n t i f i e s the inadequate communication and o r g a n i z a t i o n a l l i n k s between the community and the h e a l t h c a r e system i n f r a s t r u c t u r e . The second o r g a n i z a t i o n a l problem i s c l e a r l y a r e s u l t of the f i r s t . When the o r g a n i z a t i o n a l "support" s t r u c t u r e w i t h i n the community [eg. Community Health Committees, and Community Accounts) i s c r e a t e d by an e x t e r n a l government 101 body, there are two n o t i c e a b l e r e s u l t s : (i) the o r i g i n a l dependencies on the f o r m a l h e a l t h c a r e system are r e i n f o r c e d , and ( i i ) t h e r e i s a l a c k of commitment to these imposed s t r u c t u r e s by community members., The P r o v i n c i a l Commissioner bemoans the f a c t t h a t : The people s t a r t e d out with much enthusiasm but i n some p l a c e s people are slowing down. T h i s l e a d s t o : -(a) i r r e g u l a r , sometimes poorly attended community h e a l t h committees. (b) poor community e f f o r t s i n t h i n g s l i k e c a r r y i n g stones f o r p r o t e c t i o n of s p r i n g s . 9 2 I f i n f a c t the establishment of Community Health Committees and Community accounts are f e l t t o be the, c r e a t i o n of the government .through D i s t r i c t Health Management Teams), i t i s not s u r p r i s i n g t h a t community members experienced the Community Health Workers [CHWs) i n a s i m i l a r way. Even though they are women s e l e c t e d i n the community, they are a t t r i b u t e d the r o l e and f u n c t i o n of persons a s s o c i a t e d with government c l i n i c s . That i s , they are p e r c e i v e d t o be t r a i n e e s of the M i n i s t r y of H e a l t h [employees ?) and t h e r e f o r e purveyors of medicines. Consequently, members o f the community are making c u r a t i v e demands on the Community H e a l t h Worker (CHW) day and n i g h t , a p a t i e n t i s q u i t e w i l l i n g t o pay f o r s e r v i c e s g i v e n . For example, an a d u l t i s expected to pay 3/= ( s h i l l i n g s ) and a c h i l d ' s fee i s 1/= ( s h i l l i n g ) . T h i s money i s d e p o s i t e d i n the Community account out of which the CHW i s paid 50/= ( s h i l l i n g s ) . U n f o r t u n a t e l y , the money d e p o s i t e d from 104 c u r a t i v e s e r v i c e s i s not s u f f i c i e n t t o s u s t a i n the monthly r a t e f o r the CHW. a y e a r l y d e p o s i t of 10/= . s h i l l i n g s ) from each household i n the community would c o n t r i b u t e t o the maintenance of the account. But as the P r o v i n c i a l Commissioner remarks: People are not l i v i n g up to t h e i r own commitment of mai n t a i n i n g a community fund. In some communities, only the amount c o l l e c t e d t o open the Community account a t the Post O f f i c e Savings Bank i s the only amount s t i l l t h e r e , T h i s l e a d s to d i f f i c u l t i e s of paying the s m a l l allowance of s h i l l i n g s 50/= to the Community Health Workers.? 3 2.4.2 D i s c u s s i o n o f the M i n i s t r y of Health^s Management Problems i n Community-Based Health Care (CBHC) The management problems experienced i n the process of implementing the N a t i o n a l P i l o t P r o j e c t i n CBHC can be a t t r i b u t e d t o : (i) the imposed i n t e r v e n t i o n of t h i s supplementary h e a l t h c a r e o r g a n i z a t i o n , and ( i i ) the f a c t t h a t r u r a l communities seem t o p e r c e i v e t h i s new system i n the l i g h t of p r e v i o u s government and m i s s i o n h e a l t h care i n t e r v e n t i o n s t r a t e g i e s ( i . e . , the b u i l d i n g of s t a t i c h e a l t h f a c i l i t i e s o f f e r i n g c u r a t i v e c a r e ) . , In r e f e r e n c e t o the f i r s t cause — the f a c t t h a t i t was an imposed i n t e r v e n t i o n s t r a t e g y — i t i s c l e a r t h a t members of r u r a l communities were not responding e n t h u s i a s t i c a l l y t o the r e g u i r e d d i r e c t i v e s of "community-based h e a l t h c a r e . " For example, t h e r e was evidence o f i r r e g u l a r attendance at Community H e a l t h Committee meetings and d i f f i c u l t y i n s u s t a i n i n g the Community Hea l t h a c c o u n t s . T h i s management problem may be 105 a t t r i b u t e d t o the p r o c e s s of c o n s t r u c t i o n and the provenance and manner i n which the h e a l t h care problem was addressed. In the i n s t a n c e of the N a t i o n a l P i l o t P r o j e c t i n CBHC (sponsored by the M i n i s t r y of Health and the United Nations I n t e r n a t i o n a l C h i l d r e n ' s Emergency Fund), i t i s c l e a r t h a t the i n i t i a t i v e and source of i n s p i r a t i o n came pro forma from o u t s i d e the community and not from the d i r e c t i v e s of or through d i s c u s s i o n with respected l e a d e r s i n the community. In other words, the c r i t i c a l sequence of e v e n t s necessary f o r any community-based "development" p r o j e c t i s not experienced by community members.i They have not c o n c e p t u a l i z e d an a m e l i o r a t i v e a c t i o n to a p e r c e i v e d need, and then, o r g a n i z e d and implemented t h a t s p e c i f i c a c t i o n i n the community. For t h i s reason, there i s evidence of a l a c k of commitment t o the p r o j e c t , and as a r e s u l t , when the community i s expected t o support the p r o j e c t through the payment of Community H e a l t h Workers they are not motivated t o do so. A second c o n s i d e r a t i o n i n the d i s c u s s i o n of management problems i n CBHC programmes (as the M i n i s t r y of H e a l t h c o n s t r u c t s them) i s the image these programmes project..; S i n c e t h i s supplementary form of h e a l t h care i s a t t r i b u t e d i n design and o r g a n i z a t i o n to the government h e a l t h c a re system, i t i s a p p r o p r i a t e d and experienced i n t h i s l i g h t . Peasants i n the r u r a l areas of Kenya are s o c i a l i z e d i n t o e x p e c t i n g c l i n i c a l l y - b a s e d h e a l t h c a r e . 106 They are g u i t e w i l l i n g to pay f o r the c u r a t i v e s e r v i c e s r e c e i v e d from a h e a l t h worker (drugs, i n n o c u l a t i o n s , e t c . ) ; but not w i l l i n g to i n v e s t i n p r e v e n t i v e o r i e n t e d s e r v i c e s . Furthermore, i t would appear t h a t the Community Health Workers (CHWs) are p e r c e i v e d t o be the most p e r i p h e r a l h e a l t h care workers o f the government system and t h e r e f o r e purveyors of medicines. L i k e the Family H e a l t h F i e l d Educator before them, they are experienced as another hydrid v e r s i o n of the mainstream h e a l t h care worker., The l a r g e r problem, t h e r e f o r e , i n c o n s t r u c t i n g CBHC programmes i n t h i s manner i s t h a t the i n t e n d e d f o c u s on d i s e a s e p r e v e n t i o n and h e a l t h promotion programmes i s overloqked. 2-5 DISCPSSIOH OF THE HIHISTBY OF HEALTH'S SOCIAL CONSTRUCTION OF "COHMUNITY^BASED HEALTH CARE" 2.5.1 A Review of t h e E p i s t e m o l o g i c a l Dilemma In t h i s c h a p t e r , I r e c o n s t r u c t e d the M i n i s t r y of H ealth's c o n c e p t u a l , o r g a n i z a t i o n a l , and management views on CBHC. The proposed n a t i o n a l CBHC programme s u f f e r s , I f e e l , from the s t r a i n e d and c o m p e t i t i v e r e l a t i o n s i n t r i n s i c t o the b u r e a u c r a t i c environment and to the s u p e r o r d i n a t e r e l a t i o n between t h i s o r g a n i z a t i o n (the MOH) and r u r a l communities... On the one hand, o f f i c i a l p o l i c y makers echo the p o l i t i c a l c r y of Harambee i n v o i c i n g the need f o r CBHC programmes, while on the other hand, f o s t e r the expansion and s t r e n g t h e n i n g of c l i n i c a l s e r v i c e s . These upper l e v e l managers and d i r e c t o r s i n the M i n i s t r y of H e a l t h are caught 10.7; i n a double b i n d . They see the need f o r a "two-pronged approach" t o r u r a l h e a l t h care s e r v i c e s but t h e i r profe.ssional (and p o l i t i c a l ) i n t e r e s t s dissuade them from f u l l and honest commitment. In terms of the e f f e c t i v e u t i l i z a t i o n of r u r a l h e a l t h care s e r v i c e s , they r e a l i z e t h a t a CBHC programme [ f o c u s i n g on disease p r e v e n t i o n and h e a l t h promotion a c t i v i t i e s ) a c t u a l l y supports the i n t e l l i g e n t use of these s e r v i c e s . N e v e r t h e l e s s , by d e c i d i n g t o c o n c r e t i z e a formal p o l i c y commitment t o CBHC, p o l i c y makers would reduce the s t a t u s o f t h e i r own p r o f e s s i o n a l p o s i t i o n s (as do c t o r s , nurses, and o t h e r h e a l t h p r o f e s s i o n a l s ) and the r i g h t s and p r i v i l e g e s t h i s i n c u r s . From an economic p o i n t of view, the monies t h a t g e n e r a l l y a s s i s t i n the b u i l d i n g of s t a t i c h e a l t h f a c i l i t i e s ( h o s p i t a l , h e a l t h c e n t r e s and sub-^centres, and d i s p e n s a r i e s ) would i n f u t u r e be p a r t i a l l y d i v e r t e d to the t r a i n i n g o f Community Health Workers {CHWs); and other s u p p o r t i v e s t r u c t u r e s f o r CBHC. T h i s c o m p e t i t i v e a i d a s s i s t a n c e c o u l d s e r i o u s l y t h r e a t e n t h e i r own p r o f e s s i o n a l t r a i n i n g s c h o o l s as w e l l , and the us u a l s t a t u s i t e n j oys. I n summary, the M i n i s t r y of H e a l t h - t r a i n e d Community H e a l t h Worker (CHW) i s pe r c e i v e d t o be j u s t another k i n d of "government" h e a l t h c a r e worker. Even though the community i s made r e s p o n s i b l e f o r " s e l e c t i n g " and " s u p p o r t i n g " t h e i r CHW, the f a c t t h a t i t i s the M i n i s t r y of H e a l t h t h a t i s s u e d the d i r e c t i v e makes the CHW and the CBHC programme a 108 government i s s u e . H i s t o r i c a l l y , the M i n i s t r y of Health has been r e s p o n s i b l e f o r p r o v i d i n g a c l i n i c a l , h e a l t h care s e r v i c e . With the i n i t i a t i o n { u n i l a t e r a l i n t e r v e n t i o n ) of a CBHC programme, t h i s c u r a t i v e image o v e r r i d e s the a c t u a l motive of promoting FB and disease p r e v e n t i o n (education), programmes. As such, the CHB i s p e r c e i v e d t o be a " l o c a l d o c t o r " capable of c u r i n g and t r e a t i n g people i n the v i l l a g e s . However, had the r e been an encounter, dialogue,, or exchange of h e a l t h c a r e needs between r e s p e c t e d community l e a d e r s (those o f t e n s e l e c t e d as CHWs) and r e p r e s e n t a t i v e s of the MOH prepared to t a l k about the goals and o b j e c t i v e s of CBHC, the o p p o r t u n i t y f o r s u s t a i n e d and "mutually supported" CBHC programmes would emerge as a p o s s i b i l i t y . , In r e l a t i o n a l terms, the M i n i s t r y of H e a l t h c o n t a i n s the f o l l o w i n g t e n s i o n s and o p p o s i t i o n s towards CBHC: (i) p r o f e s s i o n a l / p o l i t i c o - e c o n o m i c and ( i i ) c u r a t i v e / d i s e a s e p r e v e n t i o n , h e a l t h promotion, and f a m i l y p l a n n i n g or clinic-based/community-based h e a l t h c a r e . That i s , the p r o f e s s i o n a l i n t e r e s t s of p h y s i c i a n s and nurses who are e n c u l t u r a t e d i n a biomedical system of h e a l t h care knowledge -- which i s a c t u a l i z e d i n the c o n s t r u c t i o n of c l i n i c a l f a c i l i t i e s o f f e r i n g c u r a t i v e care — i s in, co m p e t i t i o n with the £olitical p h i l o s o p h i e s (Harambee, 109 s e l f - h e l p development) and economic requirements ( a i d - r e l a t e d f i n a n c i a l c o n d i t i o n s ) of CBHC programmes — which emphasizes d i s e a s e p r e v e n t i o n , h e a l t h promotion, and family, p l a n n i n g programmes. Furthermore, these t e n s i o n s are exacerbated by the o r g a n i z a t i o n a l and bureaucrat t i g l i m i t a t i o n s of the M i n i s t r y of H e a l t h . :, The top-heavy a d m i n i s t r a t i o n of the MOH s e v e r e l y reduces the p o s s i b i l i t i e s f o r implementing unique and a u t h e n t i c CBHC programmes. T h i s suggests a t h i r d c o n f l i c t i n g r e l a t i o n ; ( i i i ) bureaucracy/community Indeed, o f f i c i a l s w i t h i n the M i n i s t r y of H e a l t h may wax eloquent on the wholeness and worthwhileness of "broad-based" development e f f o r t s through CBHC, and yet c o n t r a d i c t these statements i n a c t u a l government p o l i c y . 9 * The apparent dilemma w i t h i n the MQH i s t h a t these c o n t r a d i c t i o n s and the d u p l i c i t y of t h i s s i t u a t i o n i s not adequately r e s o l v e d . . 2.5.2 A C r i t i c a l Problem i n the Implementation of a Government "Community-based Health Care" Programme These values and the t e n s i o n s they invoke are r e f r a c t e d i n the person of the Community Health Worker (CHW)., Since the CBHC programmes are p e r c e i v e d to be the c r e a t i o n and i m p o s i t i o n of the government, the CHWs are a l s o i d e n t i f i e d as "government" h e a l t h c a r e workers. Even though s e l e c t e d and supposedly remunerated by the community, t h e i r p o s i t i o n and work i s a t t r i b u t e d the same meaning and subsumed by the 110 same c o n f i g u r a t i o n of h e a l t h care v a l u e s as t h a t of the M i n i s t r y of Health. The CHWs are experienced as the " l o c a l d o c t o r : " a h e a l t h c a r e worker with dawa [ K i s w a h i l i f o r drugs) who t r e a t s and c u r e s i n the community.. As p a r t - t i m e s a l a r i e d , p r o f e s s i o n a l persons, they are separated from the rank and f i l e of community members who are not p a i d f o r t h e i r work and who are a l i g n e d more immediately to t r a d i t i o n a l v a l u e s, o b l i g a t i o n s , and r e s p o n s i b i l i t i e s . For the CHW, worthwhileness i s app r e c i a t e d as advancement on the p r o f e s s i o n a l s c a l e through the ranks of the c i v i l s e r v i c e and away from t r a d i t i o n a l , moral, and community s t r u c t u r e s of a c c o u n t a b i l i t y . They are persons who s u b s c r i b e t o the s t a t u s , r o l e , and t i t l e of government " h e a l t h care worker." Consequently, the p r o f e s s i o n a l r e l a t i o n s h i p s t h a t occur i n t h e i r c a p a c i t y as CHW i s non-equivalent and n o n - r e c i p r o c a l —• i n d i c a t e d by d i a g n o s i s , p r e s c r i p t i o n , and a payment f o r s e r v i c e s rendered. That i s a l l . As such, t h i s r e l a t i o n s h i p o f CHW to community members i s broken and d i s c o n t i n u o u s , and can be symbolized with (x=±). On the other hand, because of t h e i r p r o g r e s s i v e involvement i n work with the M i n i s t r y , t h e i r r e l a t i o n s h i p s with the M i n i s t r y are continuous and not broken, and can be symbolized with (___s)« In t o t a l , the r e l a t i o n s h i p s of the CHW to community members and the there i s a c l i n i c a l c o n f r o n t a t i o n . 111 government h e a l t h care system can be diagrammed as f o l l o w s : government \ CHHs /. others community h e a l t h care members i n f r a s t r u c t u r e I d e a l l y , the o p p o r t u n i t y f o r mediating and r e c o n c i l i n g two o r g a n i z a t i o n a l systems i n CBHC programmes {that o f the h e a l t h care i n f r a s t r u c t u r e and the community) i s made p o s s i b l e through the d i a l o g u e , communication, and d i a l e c t i c t h a t i s t o l e r a t e d between them. furthermore, the community l e a d e r s who emerge as CHHs i n these c o n t e x t s a re not n e c e s s a r i l y f o r c e d t o a c t as persons f u l f i l l i n g {ordered and p r e d i c t a b l e ) r o l e s i n one system or another, but compelled by moral and e p i s t e m o l o g i c a l reasons to transcend these d i f f e r e n c e s i n the c a p a c i t y of i n d i v i d u a l s , capable of n e g o t i a t i n g both worlds. S e l f - s u s t a i n e d and a u t h e n t i c a l l y - c o n s t r u c t e d CBHC programmes o f t e n emerge i n t h i s way. Sometimes -- as i n the case of the S a r a d i d i R u r a l H ealth Development P r o j e c t {see chapter 3) — they are a d e l i b e r a t e r e a c t i o n t o government i n a c t i o n and i n e f f e c t i v e n e s s . But whatever the motive, they are always i n i t i a t e d , o r g a n i z e d , and managed on terms t h a t are ac c e p t a b l e t o community members. I f i t i s the case t h a t the M i n i s t r y o f Health i s s e r i o u s l y i n t e n t on implementing a n a t i o n a l CBHC programme, the problem i s one of how t o p r o t e c t and saf e g u a r d these CBHC programmes. I n i t i a l l y , the problem posed by 112 r e s e a r c h e r s working on the N a t i o n a l P i l o t P r o j e c t and a s s o c i a t e d with the M i n i s t r y , was how to f a c i l i t a t e the process o f "community p a r t i c i p a t i o n , " : as was e x p l a i n e d , the recourse taken by M i n i s t r y of Hea l t h o f f i c i a l s was to p r o v i d e the o r g a n i z a t i o n a l model f o r CBHC programmes, and y e t , i f the above i s s u e s are taken i n t o c o n s i d e r a t i o n , the problem becomes one of how to c o n s t r u c t u s e f u l l i n k s between the Government and the Community.. The problem of how these l i n k s can be c o n s t r u c t e d i n such a way t h a t the r e l a t i o n s h i p between the for m a l ( M i n i s t r y of Health i n f r a s t r u c t u r e ) and i n f o r m a l (community-based) h e a l t h c a r e systems develop i n t o mutually s u p p o r t i v e systems i s s t i l l t o be determined. as I see i t , t h i s a r t i c u l a t i o n and n e g o t i a t i o n of mutually s u p p o r t i v e systems i s the c r i t i c a l o r g a n j z a t i o n a . l problem (assuming, of co u r s e , t h a t the M i n i s t r y of Health i s w i l l i n g to d e f e r c o n t r o l of the p e r i p h e r a l arm of CBHC programmes t o the communities t h e m s e l v e s ) . The case s t u d i e s t h a t f o l l o w shed l i g h t on these o r g a n i z a t i o n a l and e p i s t e m o l o g i c a l c o n s i d e r a t i o n s . 113 ENDNOTES Joseph K. Wan*gombe. Economic Study, of the Community. B^sed Health Care P i l o t P r o j e c t i n Western Ken ya, I n s t i t u t e of Adul t S t u d i e s ( N a i r o b i : U n i v e r s i t y o f N a i r o b i , 1980), p. 29. C f . as w e l l : Miriam K. Sere, People's P a r t i c i p a t i o n i n t h e i r Health Care: A P r e l i m i n a r y Report on the N a t i o n a l  P i l o t P r o j e c t i n Community-Based Health Care -- A Kenyan. Experience ( N a i r o b i : M i n i s t r y of Health / Department of Community Hea l t h , F a c u l t y of Medicine, U n i v e r s i t y of N a i r o b i , 1979), Appendix, p. 5. I view "community-based h e a l t h c a r e " (CBHC) as an ejrent i n t h a t i t i s c o n s i d e r e d to operate as an i d e a , experience,, and i n t e r v e n t i o n t h a t t h r e a t e n s o r undermines e x i s t i n g premises and r e l a t i o n s i n the M i n i s t r y o f Hea l t h and t h e r e f o r e demands some form of r e s o l u t i o n , mediation, or compensation. Although the Rep u b l i c of Kenya does not have a fo r m a l p o l i c y r e g a r d i n g Primary Health Care (PHC) or CBHC as in, other A f r i c a n c o u n t r i e s , one o f f i c i a l a t the M i n i s t r y of Health - Headquarters suggests that the r e c e n t I n t e g r a t e d R u r a l H e a l t h and Fam i l y Planning Programme [IRH-FP) ; agreement can be c o n s i d e r e d a CBHC p o l i c y statement [Personal i n t e r v i e w with A s s i s t a n t Deputy D i r e c t o r of Medical S e r v i c e , R u r a l H e a l t h , 1981). M i n i s t r y of H e a l t h , The I n t e g r a t e d R u r a l H e a l t h and Family] Planning Programme, A p p r a i s a l Report [ N a i r o b i : Republic of~Kenya, 1981) 7~*P• "74. United S t a t e s Agency f o r I n t e r n a t i o n a l Development, K i t u j F e a s i b i l i t y study Report ( N a i r o b i : , USAID M i s s i o n • • to. Kenya, 1981), p. 42, emphasis added. Janovsky examines the experience, i n t e n t i o n s and a c t i o n s of the " i n d i v i d u a l " — upper l e v e l manager and a d m i n i s t r a t o r — i n the b u r e a u c r a t i c s e t t i n g of the headguarters of M i n i s t r y of Health, N a i r o b i . , Cf. G e r l i n d e K a t a r i n a Janovsky, "Planning as O r g a n i z a t i o n a l T r a n s a c t i o n and B a r g a i n i n g : The Case o f Health i n Kenya," D i s s . Harvard 1979. Frank Holmguist, " C l a s s S t r u c t u r e , Peasant P a r t i c i p a t i q n , and R u r a l S e l f - H e l p , " i n P o l i t i c s and P u b l i c P o l i c y i n Kenya and Tanzania, ed. J o e l D. Barkan, with John J . Okumu (New York, London, Sydney, Toronto: Praeger P u b l i s h e r s , 1979), p. 130. I b i d . : 135. 114 9 G e r l i u d e K a t a r i n a Janovsky, "Planning as O r g a n i z a t i o n a l T r a n s a c t i o n and B a r g a i n i n g ; The Case of H e a l t h i n Kenya," D i s s . Harvard 1979, p. 85. 10 I.E. Mburu, Mickey C. .. Smith, and Thomas B. , Sharpe, "The Determinants of H e a l t h S e r v i c e s U t i l i z a t i o n In a R u r a l Community i n Kenya," S o c i a l Science and Medicine, 12 (1978)., pp. 211-217. 11 Ecosystems L i m i t e d , "Kauwi-Kathibo fiural H e a l t h ; U n i t , Rural Health S e r v i c e s Study" ( N a i r o b i : n.p., 1979). 1 2 according to the Compact E d i t i o n of the Oxford E n g l i s h  D i c t i o n a r y (1971), a c h r o n i c l e i s "an h i s t o r i c a l record,, e s p e c i a l l y one i n which the f a c t s are n a r r a t e d without p h i l o s o p h i c treatment ..." 1 3 M i n i s t r y of H e a l t h , P r o p o s a l f o r t h e JjHproye.ae.nt of R.ur.a.1 Health S e r v i c e s and the Development of R u r a l Health T r a i n i n g Centres i n Kenya ( N a i r o b i : R e p u b l i c of Kenya, M i n i s t r y of H e a l t h , 1972), p.,2. C f . as w e l l J.N. Van L u i j k , " S o c i a l and C u l t u r a l a s p e c t s of Health and D i s e a s e , " i n Health and Disease i n Kenya, ed. L.C. Vogel, e t a l . ( N a i r o b i : E a s t A f r i c a n L i t e r a t u r e Bureau, 1974), pp. 63-73. Van L u i j k i d e n t i f i e s these r e s e a r c h needs: i) u t i l i z a t i o n of h e a l t h s e r v i c e s , i i ) e x p e c t a t i o n s and s a t i s f a c t i o n among p a t i e n t s , i i i ) reasons f o r d e f a u l t i n g both s h o r t - t e r m and long-term treatments, and iv) reasons f o r what i s considered an e x c e s s i v e demand f o r some s e r v i c e s and too low demand for. other s e r v i c e s (Ibid.:72-73)., i * M i n i s t r y of H e a l t h , P r o p o s a l f o r the Improvement of. Rural Health S e r v i c e s a n d th_e figyglopment of Rural. Health, g r a i n i n g Centres i n Ken ya ( N a i r o b i : R e p u b l i c of Kenya,. 1st A u g u s t J 1972),~p7 2." i s I b i d . : 4 . i s G e r l i n d e K a t a r i n a Janovsky, "Planning as O r g a n i z a t i o n a l T r a n s a c t i o n and B a r g a i n i n g : The Case of H e a l t h i n Kenya," D i s s . Harvard 1979, p. 144. I T f h e a d m i n i s t r a t i o n of M i n i s t r y of Health a c t i v i t i e s i s c a r r i e d out at f o u r l e v e l s : C e n t r a l , P r o v i n c i a l , D i s t r i c t , and R u r a l . a l t e r n a t i v e l y the s t r u c t u r e c o u l d be d e s c r i b e d as 115 c e n t r a l , i n t e r m e d i a t e ( p r o v i n c i a l and d i s t r i c t ) , and p e r i p h e r a l ( r u r a l ) . S. Kanani, Kenya's Maternal, C h i l d Health/Family P l a n n i n g (MCH/FP) Programme ( N a i r o b i : M i n i s t r y of Health, A p r i l 1979), p. 1. In the Republic of Kenya, t h e r e a re f o r t y D i s t r i c t s , each o f which i s su b d i v i d e d i n t o D i v i s i o n s , 1 L o c a t i o n s , and S u b - l o c a t i o n s ( I b i d . ) . i s G e r l i n d e K a t a r i n a Janovsky, "Planning as O r g a n i z a t i o n a l T r a n s a c t i o n and B a r g a i n i n g : The Case of Hea l t h i n Kenya," D i s s . Harvard 1979, p, 147. »9 I b i d . : 150. zo I b i d . : 164. 2* Republic of Kenya, Development P l a n 1979-j[983, P a r t I I (N a i r o b i : Government P r i n t e r , 1979), pp. 48-51. 22 Republic of Kenya, Development Plan 1979-1983. P a r t 3. (N a i r o b i : Government P r i n t e r , ?979) , pT~T27" ~ ~" 23 I b i d . : 136. 2 * G e r l i n d e K a t a r i n a Janovsky, "Planning as O r g a n i z a t i o n a l T r a n s a c t i o n and B a r g a i n i n g : The Case of Health i n Kenya," D i s s . Harvard 1979, p. 156. 2 5 Rural Health Development P r o j e c t (RHDP) and A d m i n i s t r a t i v e Support Unit (ASU), I n t e g r a t e d R u r a l Health S e r v i c e s Programme: Working Seminar ( N a i r o b i : M i n i s t r y of H e a l t h , 25-26~May, 1978), p.~T.~ 2* I b i d . ; 31. 27 M i n i s t r y of Health and Department of Community Hea l t h , Primary Health Care: Kenya Bxpjerience ( N a i r o b i : M i n i s t r y of Health and F a c u l t y of Medicine, U n i v e r s i t y of N a i r o b i , August 1978), p. 11. as I b i d . 2» I b i d . ; 13. 3 0 H.M. Mule, P r e p a r a t i o n of I n t e g r a t e d R u r a l Health and FP Programme [ N a i r o b i : M i n i s t r y of H e a l t h , RHDP, DEV/15/T/3, V o l . V I I I , 44, 7 August 1979), p.,1. 31 M i n i s t r y of H e a l t h , I n t e g r a t e d R u r a l H e a l t h and Family P l a n n i n g Programme: Working Document ( N a i r o b i : August 10, 1979) , p.~T. 32 I b i d . 116 3 3 I b i d . : 4, emphasis added. 3 4 M i n i s t r y of H e a l t h , The I n t e g r a t e d R u r a l H e a l t h and  Family Planning Programme, A p p r a i s a l Report [ N a i r o b i : Republic of Kenya, A p r i l 1981), p. 74. 3 5 Moris (1976) guoted i n G e r l i n d e K a t a r i n a Janovsky, "Planning as O r g a n i z a t i o n a l T r a n s a c t i o n and B a r g a i n i n g : The Case of H e a l t h i n Kenya," D i s s . Harvard 1979, p. 58. 3 6 M i n i s t r y o f H e a l t h , The I n t e g r a t e d $ u r a l Health and Family Planning Programme, Appg§i§al Report ( N a i r o b i : Republic of Kenya, A p r i l T981) , p. 78. "* 3 7 M i n i s t r y of H e a l t h , Primary Health. Care: Tanzania Experience (Par es Salaam; The Government P r i n t e r , The United Republic of Tanzania, 1978). 3 8 Abdel Bah man Kabbashi, ghe Status of £rimary {jj ea.lt h £§.£§. i n Sudan (Khartoum: M i n i s t r y of H e a l t h , May 1978). 3 9 Khanali s t a t e s t h a t : l e s s than 15% of the r u r a l p o p u l a t i o n and other u n d e r p r i v i l e g e d people are reached by e s t a b l i s h e d h e a l t h f a c i l i t i e s i n developing c o u n t r i e s . F a n i c e M. K h a n a l i , Community-Based Health Care; Speech on Community H e a l t h Carjs to F.£2.yincial Seminar with P r o v i n c i a l Heads as P a r t i c i p a n t s (Western P r o v i n c e : M i n i s t r y of H e a l t h , 3 December 1979), p.... 1..,. Dr. M. Migue and L.K. Ndungu p o s i t that "only 20-302 of the r u r a l p o p u l a t i o n a c t u a l l y b e n e f i t from and u t i l i z e r u r a l h e a l t h s e r v i c e s . " See; M. Migue and L.K. Ndungu, R u r a l H e a l t h Management -the Kenyan Experience ( N a i r o b i : M i n i s t r y of H e a l t h , ?979) 7~P- 22. F i n a l l y , Miriam K. Were s t a t e s t h a t " p o p u l a t i o n coverage with h e a l t h s e r v i c e s i s only about 20-25% i n Kenya.'» See; Miriam K. Were, People's P a r t i c i p a t i o n i n their,  Health Care: A P r e l i m i n a r y Report on the N a t i o n a l P i l o j : P r o j e c t i n Community-Based Health Care -- A Kenyan  Experience [ N a i r o b i : M i n i s t r y of Health/Department of community H e a l t h , F a c u l t y of Medicine, U n i v e r s i t y of N a i r o b i , 1979), p. 2. 4 0 M i n i s t r y of H e a l t h , P r o p o s a l f o r the Improvement of EU£&1. Health S e r v i c e s and the Development of R u r a l Health T r a i n i n g Centres i n Kenya ( N a i r o b i ; R e p u b l i c o f Kenya, M i n i s t r y of H e a l t h , 1972). 4 * R u r a l H e a l t h Development P r o j e c t , A p p r a i s a l and, g r o j e c ^ Reguest Report: The C o n s t r u c t i o n and Develop ment of Six R u r a l Health T r a i n i n g Centres [ N a i r o b i : M i n i s t r y of 117 H e a l t h , 1979). 4 2 Joseph K. Wan'gombe, Econoaic Study of the Community Based Health Care P i l o t P r o j e c t In Western Kenya, I n s t i t u t e of A d u l t S t u d i e s [ N a i r o b i : U n i v e r s i t y of N a i r o b i , 1980), p. 2. C f . as w e l l , S u r a l Health Development P r o j e c t and A d m i n i s t r a t i v e Support D nit, I n t e g r a t e d R u r a l Health S e r v i c e s Programme: Working Seminar ( N a i r o b i : M i n i s t r y o f H e a l t h , 25-26 May 1978). 4 3 E v a l u a t i o n / R e s e a r c h D i v i s i o n , N a t i o n a l F a m i l y Welfare Centre, A Report on the A c t i v i t i e s of the F i e l d Educators ( N a i r o b i : M i n i s t r y of H e a l t h , June~1978).~~ 4 4 R u r a l Health Development P r o j e c t , A p p r a i s a l and P r o j e c t Request Report: The C o n s t r u c t i o n and Development of s i x Rural Health T r a i n i n g Centres ( N a i r o b i : M i n i s t r y of H e a l t h , 1979), p. 16., 4 5 S. Kanani, Kenya's Rural Health S e r v i c e s ( N a i r o b i : M i n i s t r y of H e a l t h , Development P r o j e c t s f o r the Rural Health S e r v i c e s , 1980), p. 11. •* S. Kanani, Kenyans Maternal, C h i l d H e a l t h / Family Planning (MCH/FP) Programme ( N a i r o b i : M i n i s t r y o f H e a l t h , A p r i l 1979), p. 9. 4 7 E v a l u a t i o n / R e s e a r c h D i v i s i o n , N a t i o n a l Family Welfare Centre, A Report on the A c t i v i t i e s of the F i e l d E d ucators, 1978 ( N a i r o b i : M i n i s t r y of H e a l t h , June 1978) , p. 2. 4 8 Republic of Kenya, Development E__a.n 1979-1983., P a r t ( N a i r o b i : Government P r i n t e r , 1979), p.,131.,. 4 9 E v a l u a t i o n / R e s e a r c h D i v i s i o n , N a t i o n a l Family Welfare Centre, A Report on the A c t i v i t i e s of the F j ^ l d Educators, 1978 ( N a i r o b i : M i n i s t r y of H e a l t h , June 19 78) 7~p. 2. s 0 M i n i s t r y of H e a l t h , Family Health F i e l d Educators ( N a i r o b i : M i n i s t r y of H e a l t h , n.d.), p. 1. 3 1 E v a l u a t i o n / R e s e a r c h D i v i s i o n , N a t i o n a l Family Welfare Centre, A Report on the A c t i v i t i e s of the F i e l d  E d u c ators, 1978 ( N a i r o b i : M i n i s t r y of H e a l t h , June 1978), p. 9. 5 2 E v a l u a t i o n / R e s e a r c h D i v i s i o n , N a t i o n a l Family Welfare Centre; R e s e a r c h / E v a l u a t i o n U n i t , Family P l a n n i n g A s s o c i a t i o n of Kenya, An E v a l u a t i o n of Eie__d fidjica.tors in, Kenya - the Work Load ( N a i r o b i : M i n i s t r y of H e a l t h and 118 Family Planning a s s o c i a t i o n of Kenya, November 1979) , pp. 32 and 48. 5 3 I b i d . : 11. 5 4 S. Kanani, Kenyans B u r a l Health S e r v i c e s ( N a i r o b i ; M i n i s t r y of H e a l t h , Development P r o j e c t s f o r the S u r a l H e a l t h S e r v i c e s , 1980), p. 11. 5 5 fl. Migue and L.K. Ndungu, Rural h e a l t h Management -- the. Kenyan Experience { N a i r o b i ; M i n i s t r y of H e a l t h , 1979), p. 19. a* I b i d . , 5 7 Miriam K. Here, Eeojleis P a r t i c i p a t i o n i n t h e i r Heaj-th £§.r.e: A P r e l i m i n a r y gepgrt on the. N a t i o n a l P i l o t P r o j e c t i n qommunity-Based H e a l t h Care -- a Ken.ya.n Experience. ( N a i r o b i : M i n i s t r y of Health/Department of Community He a l t h , F a c u l t y o f Medicine, U n i v e r s i t y of N a i r o b i , 1979) , p. 8. se i b i d . ; 2-3. 5 9 See: M i n i s t r y of H e a l t h , I n t e g r a t e d R u r a l H e a l t h and Family Planning Programme (IRH2FP): a p p r a i s a l Report ( N a i r o b i : K e p u b l i c of Kenya, a p r i l 1981). *o I b i d . : 75. 61 I b i d . 6 2 i b i d . 6 3 Miriam K. Here, People's P a r t i c i p a t i o n in. t h e i r Health, Care: a P r e l i m i n a r y fieport on th.e Natjgna.1 P i l o t Prpjectj i n Sommunity-Based H e a l t h Care -- a Kenyan Exp_erienc§ ( N a i r o b i : M i n i s t r y of Health/Department of Community He a l t h , F a c u l t y o f Medicine, U n i v e r s i t y of N a i r o b i , 1979) , p. 32. C f . as s e l l , M i n i s t r y of Health and Department of Community Hea l t h , Primary Health Care; Kenya Experience ( N a i r o b i : M i n i s t r y of Health / F a c u l t y of Medicine,. U n i v e r s i t y o f N a i r o b i , august 1978), p. 15. 6 * M i n i s t r y of Health and Department of community He a l t h , Primary H e a l t h Care: Kenya Experience ( N a i r o b i : M i n i s t r y of Health / F a c u l t y of Medicine, U n i v e r s i t y of N a i r o b i , august 1978), p. ,13. 6 s i b i d . 6 6 R u r a l Health Development P r o j e c t (SHDP) and 119 a d m i n i s t r a t i v e Support Unit (ASU) , I n t e g r a t e d S u r a l H ealth S e r v i c e s Programme: Working Seminar (Nairobi:. M i n i s t r y of H e a l t h , 25-26 May, 1978)*, p 7 ~ T 9 , ~ " " 6 7 M i n i s t r y of H e a l t h and Department of Community H e a l t h , Primary Health Care: Kenya Experience [ N a i r o b i : M i n i s t r y of H e a l t h / F a c u l t y of Medicine7~ U n i v e r s i t y of N a i r o b i , August 1978) , pp. 13-14., 6 8 M i n i s t r y of Health and Department of Community Health, Primary H e a l t h Care: Kenya Experience ( N a i r o b i : M i n i s t r y of Health and F a c u l t y of Medicine, U n i v e r s i t y of N a i r o b i , august 1978), p. 11. 6 9 Miriam K. Were, People's P a r t i c i p a t i o n i n tfcejjc Ije.al.th, Care: A P r e l i m i n a r y Report on the N a t i o n a l P i l o t P r o j e c t i n Community-Based He a l t h Care -- I Kenyan Experience ( N a i r o b i : M i n i s t r y of Health/Department o f Community Health, F a c u l t y of Medicine, U n i v e r s i t y of N a i r o b i , 1979) , p. 4. 7 0 I b i d . 7 1 See the chapter on the S a r a d i d i S u r a l H e a l t h Development P r o j e c t where " v i l l a g e s " are s u b - u n i t s w i t h i n the l a r g e r "community" o r g a n i z a t i o n . Each v i l l a g e s e l e c t s members t o form the V i l l a g e Health Committee which manages the P r o j e c t ' s a f f a i r s i n t h e i r a rea. 7 2 The r a t i o n a l e f o r u s i n g the s o c i a l u n i t of "community" over and above " v i l l a g e " or " c l a n " w i l l become c l e a r e r i n the two case s t u d i e s t h a t f o l l o w . 7 3 The S e p u b l i c of Kenya i s d i v i d e d i n t o these a d m i n i s t r a t i v e u n i t s ; P r o v i n c e s , D i s t r i c t s , D i v i s i o n s * . L o c a t i o n s , and Sub-Locations. V i l l a g e s are the i n f o r m a l u n i t s w i t h i n the s u b - l o c a t i o n and are a d m i n i s t e r e d by headmen ( l i g u r u s ) who a r e r e s p o n s i b l e to the government appointed c h i e f s i n the l o c a t i o n . , 7 * Miriam K. Were, People's P a r t i c i p a t i o n i n t h e i r Health; Care: A P r e l i m i n a r y Report on the N a t i o n a l P i l o t P r o j e c t i n Community-Based H e a l t h Care --- A Kenyan Experience ( N a i r o b i : M i n i s t r y of Health/Department of Community He a l t h , F a c u l t y of Medicine, U n i v e r s i t y of N a i r o b i , 1979) , p. 5. 7 s i b i d . 7 6 R u r a l Health Development P r o j e c t and A d m i n i s t r a t i v e Support U n i t , I n t e g r a t e d Rural Health S e r v i c e s Programme: Working Seminar ( N a i r o b i : M i n i s t r y of H e a l t h , 25-26 May* 1978) , p. 32." 120. 7 7 i b i d . : 31. 7 « Fariice M. K h a n a l i , "Community-Based Health Care," Speech on Community He a l t h Care t o P r o v i n c i a l Seminar with P r o v i n c i a l Heads as P a r t i c i p a n t s , Western P r o v i n c e , December 3, 1979, p. 3. 7 9 I b i d . : 3. 8 0 M i n i s t r y of H e a l t h , The I n t e g r a t e d R u r a l H e a l t h and] Family P l a n n i n g Programme, A p p r a i s a l Report (Nairobi:. Republic of Kenya, A p r i l 1981) , pp. ,74-75. , 8 * Miriam K. Were, People's P a r t i c i p a t i o n - i n t h e i r Health Care: A P r e l i m i n a r y Report on the N a t i o n a l P i l o t P r o j e c t i n Community-Based H e a l t h Care ~ A Kenyan Experience ( N a i r o b i : M i n i s t r y of Health/Department o f Community H e a l t h , F a c u l t y of Medicine, U n i v e r s i t y o f N a i r o b i , 1979) , pp. 13-14. 8 2 Joseph K, Wan'gombe, Economic Study of the Community Based Health Care P i l o t P r o j e c t In• Western Kenya, I n s t i t u t e of A d u l t S t u d i e s ( N a i r o b i : U n i v e r s i t y o f N a i r o b i , 1980), p.,34. 8 3 C f . Were and Wan'gombe a r t i c l e s above., The P r o v i n c i a l Commissioner's (J.G. Mburu's) speech i s appended to the Were a r t i c l e . , 8 * Joseph K. , wan'gombe. Economic Study of the Community, Based Health Care P i l o t P r o j e c t In Western Kenya, I n s t i t u t e of A d u l t S t u d i e s [ N a i r o b i : U n i v e r s i t y of N a i r o b i , 1980), p. 1. i b i d . : 2. 8 * Miriam K. Were, People's P a r t i c i p a t i o n i n t h e i r H e a l t h Care: A P r e l i m i n a r y Report on the Nationa.1 P i l o t P r o j e c t i n Community-Based H e a l t h Care A Kenyan Experience [ N a i r o b i : M i n i s t r y of Health/Department of Community H e a l t h , F a c u l t y o f Medicine, U n i v e r s i t y of N a i r o b i , 1980) , p. 14. 8 7 i b i d . : 5. 8 8 M i n i s t r y o f Hea l t h , The I n t e g r a t e d R u r a l Health andj Family P l a n n i n g Programme, A p p r a i s a l Report ( N a i r o b i : Republic of Kenya, A p r i l 1981), p. 76. 8 9 Joseph K. Wan'gombe, Economic Study of the Community.  Based Health Care P i l o t P r o j e c t In Western Kenya, I n s t i t u t e of A d u l t S t u d i e s ( H a i r o b i : U n i v e r s i t y o f N a i r o b i , 1980). 121 9 0 Miriam K. Here, People^s P a r t i c i p a t i o a i n t h e i r H ealth Care: A P r e l i m i n a r y Report on the N a t i o n a l P i l o t Project; l a Community-Based He a l t h Care -- A Kenyan Experience, ( N a i r o b i : M i n i s t r y of Health/Department of Community Health, F a c u l t y of Medicine, U n i v e r s i t y o f N a i r o b i , 1980) , Appendix, 9 » i b i d . : 4. «z I b i d . 9 3 Miriam K. Here, PeopJLg^s P a r t i c i p a t i o n i n t h e i r Health, Care: A P r e l i m i n a r y Be p o r t on the Nationa.1 P i l o t P r o j e c t i n Community-Based H e a l t h Care -- A Kenyan Experience ( N a i r o b i : M i n i s t r y of Health/Department of Community Health, F a c u l t y o f Medicine, U n i v e r s i t y of N a i r o b i , 1979) , p. 4. 9 * F. M. Mburu c a l l s the r e s u l t a n t e f f e c t between what i s p u b l i c a l l y promised and what i s a c t u a l l y implemented by M i n i s t r y of H e a l t h o f f i c i a l s the " r h e t o r i c ^ i m p l e m e n t a t i o n gap." See: F. M. Mburu, "Rhetoric-Implementation Gap i n Health P o l i c y and H e a l t h S e r v i c e s D e l i v e r y f o r a R u r a l P o p u l a t i o n i n a Developing Country," S o c i a l S c i ence and Medicine, 13A, 1979, pp. 577-583. Chapter I I I THE SARADIDI RURAL HEALTH DEVELOPMENT PROJECT: THE CASE OF AM INDEPENDENTLY CONSTRUCTED CBHC PROGRAMME 3. 1 INTRODUCTION I examine i n t h i s chapter an o c c a s i o n where a community-based h e a l t h c a r e (CBHC) programme i s being c o n s t r u c t e d by an i n d e p e n d e n t l y - o r g a n i z e d , r u r a l , peasant community. The S a r a d i d i R u r a l H e a l t h Development P r o j e c t (SRHDP) :— as i t i s known i n the community of Asembo East and Asembo West s u b - l o c a t i o n s — i s perhaps the onl y CBHC programme i n the R e p u b l i c of Kenya t h a t has been i n i t i a t e d without the e x t e r n a l i n t e r v e n t i o n of government, m i s s i o n h o s p i t a l , r e s e a r c h , or a i d o r g a n i z a t i o n . 1 I t i s i n every r e s p e c t a "community-based" development e f f o r t : the S a r a d i d i community has not only implemented a Community Hea l t h Worker (CHW) programme emphasizing d i s e a s e p r e v e n t i o n , h e a l t h promotion, and f a m i l y p l a n n i n g , but has c o n s t r u c t e d the c l i n i c a l support s t r u c t u r e as w e l l through the c r e a t i o n of the S a r a d i d i " s e l f h e l p " c l i n i c . In l i g h t of t h i s unique-example of community-based i n n o v a t i o n and s e l f - d e t e r m i n i s m , i t p r o v i d e s a u s e f u l case study, f o r comparison with: (i) CBHC programmes t h a t are i n i t i a t e d through the s t r a t e g i c i n t e r v e n t i o n s of non-government o r g a n i z a t i o n s (see chapter - 122 -123 4), as w e l l as with ( i i ) the model f o r CBHC proposed by the government through the M i n i s t r y of Health (see chapter 2 ) . The i n t e n t i o n of t h i s chapter i s toe (i) r e c o n s t r u c t the h i s t o r i c a l and c o n c e p t u a l process f o r the development of the S a r a d i d i CBHC programme, and to ( i i ) d e s c r i b e the 2£2§ai2ational s t r u c t u r e t h a t has emerged t o manage the. programme, Since the S a r a d i d i CBHC programme was s t i l l i n i t s e a r l y stages of development while I was i n the f i e l d — i t had only begun a y e a r p r i o r to my v i s i t i n g the ar e a f o r the f i r s t time — I am unable to address the long-term management i s s u e s o f the programme- The o r g a n i z a t i o n a l s e c t i o n , however, breaks down i n t o a d i s c u s s i o n of the experience and a c t i v i t i e s of the P r o j e c t D i r e c t o r (PD), the Ex e c u t i v e Committee (EC), the V i l l a g e H e a l t h Committees (VHCs), and the V i l l a g e H e l p e r s Towards H e a l t h fVHsTH). In the process of e l u c i d a t i n g the conceptual and o r g a n i z a t i o n a l framework of the P r o j e c t , I d i s c u s s the e p i s t e m o l o g i c a l r e l e v a n c e s and determinants t h a t i n f l u e n c e the p a r t i c i p a t i o n of members i n the S a r a d i d i R u r a l Health Development P r o j e c t (SRHDP) . In s p i t e of i t s independent stance i n r e l a t i o n t o other CBHC programmes t h a t are emerging i n Kenya, there i s evidence of s i m i l a r l y d e r i v e d t e n s i o n s which impinge on the development experience of P r o j e c t members (see c h a p t e r s 2 and 4 ) . The Luo community of S a r a d i d i i s i n v o l v e d i n a peasant economy, as such, they experience the d i s c r e p a n c i e s 12% and pressures of a modern, complex economy which i n f l u e n c e s and threatens to fragment t r a d i t i o n a l s u b s i s t e n c e - based v a l u e s . These moral s e p a r a t i o n s d r a m a t i c a l l y a f f e c t the p r o c e s s of c r e a t i n g and implementing the S a r a d i d i CBHC programme. For example, t h e r e e x i s t s an element of t e n s i o n i n t h e l e a d e r s h i p s t r u c t u r e between t r a d i t i o n a l e l d e r s ( i n Luo, jodonqo) and the new p r o f e s s i o n a l e l i t e of businessmen, te a c h e r s , headmasters, and other p r o f e s s i o n a l s i n the P r o j e c t a r e a . T h i s d i s j u n c t i o n i n l e a d e r s h i p given t o the P r o j e c t i s most ev i d e n t i n the g o a l s and o b j e c t i v e s a r t i c u l a t e d by these persons. Simply s t a t e d — although i t i s somewhat u n f a i r to make sweeping g e n e r a l i z a t i o n s of a l l persons i n these groups — the l e a d e r s who are the new p r o f e s s i o n a l e l i t e have been accused of s e e k i n g the s t a t u s and attendant s a l a r y 2 they f e e l i s owed them as members of the E x e c u t i v e Committee (EC) . They say t h a t these f i n a n c i a l rewards would be generated through the income-generating p r o j e c t s i n each v i l l a g e . The t r a d i t i o n a l e l d e r s who a r e p a r i s h l e a d e r s , l a y r e a d e r s , c l a n group [dhoot i n Luo) e l d e r s , a l t e r n a t i v e l y , maintain t h a t these b e n e f i t s should serve the "community good" and that i t be accomplished i n the s p i r i t of a l t r u i s m and e g a l i t a r i a n i s m . I t w i l l become c l e a r i n t h i s c h apter t h a t these t e n s i o n s and d i s c r e p a n c i e s i n a c c o u n t a b i l i t y s t r u c t u r e s — between a s e l f - s e r v i n g , p e r s o n a l f o c u s and t h a t of the i n t e r e s t o f the l a r g e r c o m m u n i t y — i s a c e n t r a l 125 i s s u e i n the understanding of the S a r a d i d i R u r a l Health Development P r o j e c t . N e v e r t h e l e s s , the dominant f o r c e at work i n the P r o j e c t i s towards the i n t e g r a t i o n and st r e n g t h e n i n g of community bonds; i n other words,: t r a d i t i o n a l s t r u c t u r e s of a u t h o r i t y seem to p r e v a i l over t h a t of a t o m i s t i c and s e l f - s e r v i n g i n f l u e n c e s [egs., p r o f e s s i o n a l s t a t u s , t i t l e s , and advancement). There are a number of reasons why t h i s s hould be so, but fundamentally, the people of S a r a d i d i have p e r c e i v e d "community-based h e a l t h c a r e " as an event and o p p o r t u n i t y to accomplish a worthwhile e n t e r p r i s e t o g e t h e r . They b e l i e v e t h a t i n order to "develop themselves," they w i l l need tq transcend t h e i r r i v a l and r e l i g i o u s d i f f e r e n c e s , and as a r e v i t a l i z e d community work a t the a m e l i o r a t i o n of t h e i r f e l t - n e e d s . , As a r e s u l t , they have d e f i n e d the boundaries of the S a r a d i d i P r o j e c t area { i . e. the community),. i d e n t i f i e d p o t e n t i a l n o n - p a r t i c i p a n t s i n the P r o j e c t and persuaded them to g e t i n v o l v e d { i .e. independent church groups), and n e g o t i a t e d with c l a n and church groups t o meet as a c o l l e c t i v i t y of persons i n the S a r a d i d i R u r a l H e a l t h Development P r o j e c t . , While c e r t a i n workers i n the SRHDP have c o n t r i b u t e d more e x p l i c i t l y t o the c o n s t r u c t i o n of the S a r a d i d i CBHC programme £egs. the Community H e a l t h Workers), no one group, a c t o r , o r cadre of workers can take the f u l l c r e d i t f o r the s u c c e s s f u l development {to date) o f the SRHDP. I t i s a community p r o j e c t . 126 A s i g n i f i c a n t element i n t h i s process has been the re-emergence and r e v i t a l i z a t i o n of t r a d i t i o n a l r o l e s and p o s i t i o n s . The nyamreyua. 3 f o r example, was the name f o r the t r a d i t i o n a l h e a l t h care p r a c t i t i o n e r i n Luo c u l t u r e (a h e a l e r who was both h e r b a l i s t and t r a d i t i o n a l b i r t h a t t e n d a n t ) . Those persons i n the S a r a d i d i community who have worked as nyamrerua i n the past have been ( i n most in s t a n c e s ) the persons t o be t r a i n e d as Community H e a l t h Workers (in the SRHDP they have been named V i l l a g e H e l p e r s Towards Health) . The jodongo or l i n e a g e e l d e r s have been i n v e s t e d with the r e s p o n s i b i l i t i e s of o r g a n i z i n g t h e i r c l a n and v i l l a g e members i n t o the a c t i v i t i e s of the P r o j e c t : s e l e c t i n g t h e i r r e p r e s e n t a t i v e h e a l t h c a r e worker (the nyamrerua). i d e n t i f y i n g the s p e c i f i c needs o f t h e i r a r e a , and i n i t i a t i n g an a p p r o p r i a t e income-generating p r o j e c t . Many of these jodongo s i t on the r e s p e c t i v e V i l l a g e Health Committees (VHCs) i n the P r o j e c t . While the c h i e f o f Asembo Eas t has emerged as the £atron of the S a r a d i d i R u r a l Health Development P r o j e c t (SRHDP), the newly e l e c t e d Projects D i r e c t o r has come to mediate and f a c i l i a t e r e l a t i o n s with o r g a n i z a t i o n s and groups ou t s i d e of the P r o j e c t area (egs., donors, r e s e a r c h o r g a n i z a t i o n s , and government agencies).. In t h i s c a p a c i t y , the P r o j e c t D i r e c t o r has assumed a r o l e i n the community s i m i l a r i n f u n c t i o n t o the r o l e t r a d i t i o n a l l y h e l d by the. j a b i l o . 4 I n former times during a p e r i o d of c r i s i s , the l a b i l o appeared as the s p i r i t u a l and c h a r i s m a t i c 127 l e a d e r who organized the separate clan-based t e r r i t o r i a l groups (gweng) i n t o the l a r g e r community of the s u b t r i b e (oganda or community). In the present s i t u a t i o n , the, P r o j e c t D i r e c t o r i s expected to r e p r e s e n t the i n t e r e s t s of the community i n n e g o t i a t i o n s with a u t h o r i t i e s (economic* p o l i t i c a l , and e x p a t r i a t e ) o u t s i d e of the boundaries of the P r o j e c t . While the P r o j e c t D i r e c t o r i s not known by p r o j e c t p a r t i c i p a n t s as a j a b i l o , i n the context of t r a d i t i o n a l Luo i n s t i t u t i o n s and r o l e s b e i n g r e v i t a l i z e d f o r the purposes of advancing the CBHC programme, he does f u l f i l l an analogous f u n c t i o n . The c r i s i s i n t h e S a r a d i d i community today i s the d e s p e r a t e l y f e l t problems of potable water, pove r t y , unemployment, m a l n u t r i t i o n , the endemic d i s e a s e of m a l a r i a , and the preventable i l l n e s s e s of c h o l e r a , d i a r r h o e a l d i s e a s e s , and measles. To a m e l i o r a t e the problems, a l l of these i d e n t i f i a b l e l e a d e r s i n the S a r a d i d i Rural Health, Development P r o j e c t (SRHDP) — nyamrerua, jodongo, and j a b i l o — have c o n t r i b u t e d i n t h e i r own way t o make the P r o j e c t a v i a b l e , and s e l f - s u s t a i n e d development project.; N e v e r t h e l e s s , i t i s the Community Health Workers (CHWs) or V i l l a g e Helpers Towards He a l t h (VHsTH) who* because of t h e i r r o l e as "immediate h e l p e r i n times of t r o u b l e , " image and r e f r a c t most e x p l i c i t l y the problems, e x p e r i e n c e , and the d i a l e c t i c e v i d e n t i n the e v o l u t i o n of the SRHDP., They are compelled to f u l f i l l not only the t r a d i t i o n a l requirements 128 of the Luo nyamrerua, but a l s o (in some in s t a n c e s ) , . they are t o r n by the y e a r n i n g s f o r s a l a r y and s t a t u s t h a t other p e r i p h e r a l h e a l t h care workers have enjoyed ( f o r example, the Family Health F i e l d Educators employed by the M i n i s t r y of H e a l t h ) . While these p r o p e n s i t i e s are j u s t i f i e d and economically r a t i o n a l given t h e i r p o s i t i o n "betwixt and between" competing s o c i a l o r d e r s , the l a r g e r t r u t h s of the community whole -- a r t i c u l a t e d by any number of the community's l e a d e r s -- have gathered these t e n d e n c i e s i n s e r v i c e o f the c o l l e c t i v i t y . I t i s t h i s e p i s t e m o l o g i c a l r e l e v a n c e t h a t I wish to understand i n determining how CBHC has become a p o s s i b i l i t y i n the Luo community of S a r a d i d i . 3.2 SETTING 3.2.1 Climate and Environment S a r a d i d i R u r a l H e a l t h Development P r o j e c t (SRHDP) i s s i t u a t e d i n the two s u b - l o c a t i o n s of Asembo East and Asembo West, Siaya D i s t r i c t , Nyanza Province. I t l i e s approximately f o r t y m iles west of the town of Kisumu and can be reached by p u b l i c t r a n s p o r t (bus or matatu) s from the g r a v e l road t h a t d i v i d e s the two s u b - l o c a t i o n s and extends from the Bondo-Kisumu road down to Asembo Bay on Lake V i c t o r i a (see F i g u r e 6 ) . Asembo Bay was p r e v i o u s l y a t h r i v i n g p o r t town and t r a d i n g c e n t r e operated by Indian merchants.• Today t h e r e are a few dukas ( K i s w a h i l i f o r s m a l l shops) t a couple of 129 F i g u r e 6. S i t e o f S a r a d i d i Rural H e a l t h Development P r o j e c t , S i a y a D i s t r i c t , Nyanza P r o v i n c e , Kenya Adapted from: The World Bank, Kenya: P o p u l a t i o n and Development (Washington, D.C.: Development Economics Department, E a s t A f r i c a C o u ntry Programs Department, The World Bank, 1980), Regions and D i s t r i c t s Map. 130, A f r i c a n owned h o t e l s , and a p e t r o l s t a t i o n . In most cases, v i s i t o r s to the S a r a d i d i P r o j e c t w i l l stay a t " S i g a r and Company." T h i s h o t e l which i s owned by a wealthy Luo merchant has enjoyed a t h r i v i n g b u s i n e s s because of i t s pr o x i m i t y t o the P r o j e c t . R e p r e s e n t a t i v e s from Family Planning I n t e r n a t i o n a l A s s i s t a n c e (FPIA) , I n t e r n a t i o n a l Eye Foundation (IEF), World Neighbors, A f r i c a n M e d i c a l and Research Foundation (AMREF), World Health Organization. (WHO), United Nations I n t e r n a t i o n a l C h i l d r e n ' s Emergency Fund (ONICEF), Tear Fund, and c i v i l s e r v a n t s from Kisumu and N a i r o b i lodge t h e r e . Asembo Bay has the f e e l i n g of being o f f the beaten t r a c k . I t i s remote, b e a u t i f u l i n i t s p o s i t i o n by the Lake, but i n appearance l i k e a ghost town t h a t has seen a l i v e l i e r day. The medical s t u d e n t s from the U n i v e r s i t y of N a i r o b i who were i n v o l v e d i n the "community d i a g n o s i s " 6 f o r the P r o j e c t s t a y e d at Lwak; i t i s approximately 7 k i l o m e t r e s away from the P r o j e c t ' s c e n t r e . There i s a Roman C a t h o l i c M i s s i o n H o s p i t a l and adjacent maternity c e n t r e at Lwak and a g i r l s secondary s c h o o l run by the same mission. As i n Asembo Bay, there i s a market c e n t r e a t Lwak and i n the surrounding v i l l a g e s of Ndori and S a r a d i d i . On the market days held twice-weekly at these c e n t r e s , the Luo peasants can buy herbs, v e g e t a b l e s , f r e s h meat, bread, and d r i e d f i s h . The dukas (small shops) s e l l other household items such as matches, t e a , 0M0 [the detergent f o r washing c l o t h e s ) , and cooking o i l (Blue Band margarine). 131 Coming from the c o o l and h i g h l a n d t e r r i t o r y around N a i r o b i , the area around S a r a d i d i i s experienced to be hot and humid. P r o x i m i t y t o Lake V i c t o r i a c o n t r i b u t e s to t h i s heat and humidity as does a d e c l i n e i n e l e v a t i o n from 5,280 f e e t (Nairobi) to approximately 3,720 f e e t above sea l e v e l ( S a r a d i d i ) . , another f a c t o r i s i t s l o c a t i o n a few miles from the equator., There are two r a i n y seasons: the long r a i n s occur roughly between Harch and June and the s h o r t r a i n s i n October and November. During the r a i n y seasons the roads are f r e q u e n t l y impassable. I t i s not uncommon, f o r i n s t a n c e , t o see buses s w o l l e n i n r e d d i s h mud a t the s i d e of the road or matatus s t u c k on the road with i t s passengers h e l p l e s s l y s t a n d i n g by. Xet, the r a i n s a r e a welcome s i g h t a f t e r months of drought and dust. Both men and women are f u l l y i n v o l v e d i n the p l a n t i n g of maize, m i l l e t , cassava* peas, and groundnuts i n the sandy s o i l , so as to feed t h e i r l a r g e f a m i l i e s . The s o i l i s weak, however, due to o v e r - p l a n t i n g , o v e r - g r a z i n g , and the s o i l e r o s i o n t h a t comes with the heavy r a i n s . The o v e r - r u t i l i z a t i o n of the l a n d i s a r e f l e c t i o n of the l a n d shortage due to the population, pressure and d i s a l l o w s the necessary crop r o t a t i o n . In the main, these s u b s i s t e n c e a g r i c u l t u r a l i s t s cum p a s t o r a l i s t s grow what they e a t , but i n most ca s e s , are unable t o s t o r e enough t o c a r r y them from harvest to h a r v e s t . There are a few f a m i l i e s i n the area t h a t grow c o t t o n as a cash crop t o supplement t h e i r s u b s i s t e n c e a c t i v i t i e s , but with an. 132 inadequate c r e d i t and marketing i n f r a s t r u c t u r e , t h e r e are few i n c e n t i v e s to develop t h i s area i n t h i s way. G e n e r a l l y speaking, the Luo people i n t h i s area of Hyanza P r o v i n c e are very poor. I t i s estimated t h a t only e l e v e n percent of the p o p u l a t i o n i n the S a r a d i d i P r o j e c t area are s a l a r i e d or r e c e i v e a r e g u l a r income through self-employment. 7 3.2.2 P o p u l a t i o n and H e a l t h Heeds The S a r a d i d i R u r a l H e a l t h Development P r o j e c t (SRHDP) i s organized i n t o t h r e e areas (A,B,C) . Each o f these three areas has an estimated p o p u l a t i o n of 15,000 persons, and i n the next t h r e e y e a r s , i t i s hoped t h a t approximately 50,000. people w i l l be i n v o l v e d i n the P r o j e c t . To d a t e , t h e r e are 15,000 people who have been i n t e r v i e w e d i n the household surveys and who have organized themselves i n t o V i l l a g e H ealth Committees (VHCs) . Before the b u i l d i n g of the S a r a d i d i Dispensary on a s e l f - h e l p b a s i s , the n e a r e s t h e a l t h s e r v i c e s were a t Lwak which i s seven k i l o m e t r e s away from the S a r a d i d i P r o j e c t c e n t r e , and at O n g ' i e l o , a government d i s p e n s a r y t h i r t e e n k i l o m e t r e s away. The c l o s e s t government h o s p i t a l i s at S i a y a which i s t h i r t y k i l o m e t r e s from the P r o j e c t c e n t r e . I t i s q u i t e c l e a r t h a t u n d e r u t i l i z a t i o n 8 of e x i s t i n g s e r v i c e s i s a s e r i o u s problem t h a t i s exacerbated by t r a n s p o r t a t i o n and communication problems. There are no 133 telephone s e r v i c e s or ambulances a v a i l a b l e f o r s e r i o u s i l l n e s s cases, and consequently, when v i s i t o r s come to the area with v e h i c l e s they are f r e q u e n t l y approached t o a s s i s t i n emergencies. The i l l n e s s experience i s an everyday r e a l i t y f o r the people of t h i s a r ea. M a l a r i a i s probably one of the most s e r i o u s d i s e a s e s e x p e r i e n c e d . I t i s endemic t o t h e a r e a and a f f e c t s mainly c h i l d r e n under f i v e years of age and women who are pregnant. U n d e r n u t r i t i o n and m a l n u t r i t i o n are a l s o s e r i o u s problems. F o r t y percent o f the c h i l d r e n under three, years of age are i n t h i s category; out of t h i s an e s t i m a t e d f i v e t o t e n percent a r e s e v e r e l y malnourished. 9 Other causes o f m o r t a l i t y and m o r b i d i t y are d i a r r h p e a l d i s e a s e s (approximately e i g h t y percent of c h i l d r e n under f i v e years o f age have worm i n f e s t a t i o n s ) , and measles* f° an i n t e g r a l f a c t o r determining most of these d i s e a s e problems i s the inadequate water supply f o r the community. Streams remain, unprotected, and d u r i n g the dry season, women are known to spend up to s i x hours a day walking to and from Lake V i c t o r i a t o o b t a i n water f o r t h e i r households. 3-3 CONCEPTUALIZATION AND INITIATION OF THE SARADIDI BUBAL] HEALTH DEVELOPMENT PROJECT (SRHDP)" This i s a community p r o j e c t , not a church p r o j e c t ! (Executive Committee member, SRHDP) T h i s s e c t i o n addresses the i s s u e of o r i g i n s of the S a r a d i d i R u r a l H e a l t h Development P r o j e c t (SRHDP). To 134 b e g i n , I attempt a r e c o n s t r u c t i o n of the o r d e r i n g o f events t h a t l e d t o the i n i t i a t i o n of the P r o j e c t . T h i s c h r o n i c l e of events w i l l be f o l l o w e d by a d i s c u s s i o n of the conc e p t u a l p r o c e s s t h a t l e d to the (i) b u i l d i n g of the s e l f - h e l p d i s p e n s a r y , and ( i i ) the subseguent t r a i n i n g of V i l l a g e H e l p e r s Towards H e a l t h (VHsTH). As a P r o j e c t t h a t i s independent i n d e r i v a t i o n , I w i l l attempt t o i s o l a t e the nature of the i n f l u e n c e s t h a t caused i t to be an u n i q u e l y community-based p r o j e c t , and to expose the e p i s t e m o l o g i c a l r e l a t i o n s and o r i e n t a t i o n s that have a f f e c t e d i t s development., 3*3.1 4 Skcaaicle of ££0jeci gvgatS Most o f the people i n v o l v e d i n the SRHDP t r a c e the gene s i s of the P r o j e c t t o the church. Dr. P. 1 1 s t a t e s t h a t a number o f e l d e r s i n the S a r a d i d i p a r i s h church [an An g l i c a n denomination o f the Church of the Pr o v i n c e of Kenya) were prompted by the h e a l t h problems i n the area and by the r e a l i z a t i o n t h a t the Government c o u l d not make i t s s e r v i c e s u n i v e r s a l l y a v a i l a b l e and a c c e s s i b l e to the ma j o r i t y o f the people of S a r a d i d i . 4 2 At that time, the only a v a i l a b l e h e a l t h care s e r v i c e i n the p a r i s h community was the work of the h e a l t h s e c r e t a r y . T h i s person would r e c e i v e a r e g u l a r supply of b a s i c drugs (Chloroquin t a b l e t s f o r m a l a r i a . A s p i r i n , etc.), and f i r s t a i d s u p p l i e s from the Development O f f i c e o f the Diocese of, Mase.no S.outh. These s u p p l i e s would be given on a l o a n b a s i s 135 and reimbursed a f t e r the h e a l t h s e c r e t a r y s o l d the drugs to persons i n the p a r i s h community. 1 3 U n f o r t u n a t e l y , the persons who b e n e f i t e d most from these l i m i t e d h e a l t h care r e s o u r c e s were only the members of the S a r a d i d i church community ( i . e . the Church of the Province of Kenya) and not the people i n the l a r g e r community of Asembo East and Best. Even then, the s e r v i c e s a v a i l a b l e f o r t h i s s m a l l e r community were inadequate. Hhen Dr. P. returned t o S a r a d i d i a f t e r a two year absence overseas, he was a l e r t e d t o the d i s c u s s i o n s going on among the community members. The c l a n and church l e a d e r s were v o i c i n g s i m i l a r concerns and were i n t e n t on doing something about the problems experi e n c e d i n the area -- the problems of an inadequate water sup p l y , the l a c k of a h e a l t h care s e r v i c e f a c i l i t y i n the community, and the pr e v a l e n c e of d i s e a s e s t h a t were p r e v e n t a b l e . Siven the h e a l t h - r e l a t e d f o c u s of these needs. Dr. P. f e l t t h a t the method of Primary H e a l t h Care (PHC) or Community-Based H e a l t h Care (CBHC), would be an e f f e c t i v e way of a d d r e s s i n g these community problems., M. and S., two medical students at the University, of N a i r o b i and a l s o r e s i d e n t s of the a r e a , supported Dr. P. i n t h i s recommendation. In February of 1979, the Rural Development Committee i n the S a r a d i d i CPK c h u r c h 1 4 acted on t h i s s u g g e s t i o n and e l e c t e d members t o a t a s k group that was c a l l e d t h e I n t e r i m Committee. The f u n c t i o n of the I n t e r i m Committee was to 136 " c r e a t e a w a r eness" 1 5 i n the church membership to the n o t i o n of community-based h e a l t h care (CBHC). A f t e r a three month p e r i o d , church members and non-church members a l i k e were, persuaded t o get i n v o l v e d i n t h i s community programme. Everyone f e l t and c o u l d agree on the e s s e n t i a l needs of the a r e a : c l e a n s o u r c e s of p o t a b l e water, an a c c e s s i b l e c l i n i c d e l i v e r i n g comprehensive h e a l t h care s e r v i c e s , a b e t t e r developed system of t r a n s p o r t a t i o n and communication, and the d e s i r e to get i n v o l v e d i n income-generating p r o j e c t s to i n c r e a s e the standard of l i v i n g i n the area., I t was e v i d e n t to the gala moro (Luo f o r the community or p u b l i c at large), t h a t i t was f u t i l e t o wait f o r the government t o p r o v i d e a s s i s t a n c e . I f a n y t h i n g c o n s t r u c t i v e was to be done, i t would have t o be done by and through the e f f o r t s of the community. A f t e r these i n i t i a l e f f o r t s , the members of the S a r a d i d i I n t e r i m Committee c o n t i n u e d with the task of o r g a n i z i n g the P r o j e c t . , With the a s s e n t of the community behind them — agreed upon a t the p u b l i c baraza ( K i s t f a h i l i f o r a p u b l i c g a t h e r i n g or meeting) — they began t o look f o r a s u i t a b l e p i e c e of l a n d on which t o b u i l d a permanent s t r u c t u r e . , T h i s s t r u c t u r e would be the S a r a d i d i c l i n i c (see F i g u r e 7) and would act as a r e f e r r a l f a c i l i t y f o r the V i l l a g e H elpers Towards Health (VHsTH) and a p l a c e t o keep the r e c o r d s f o r the P r o j e c t . , Figure 7. Saradidi C l i n i c 137 Two photographs of the p a r t i a l l y constructed health care c l i n i c on the s i t e of the Saradidi Rural Health Development Project. 138 I n c o n j u n c t i o n with the c l a n e l d e r s i n the community, the I n t e r i m Committee decided on a s u i t a b l e s i t e a p p r o p r i a t e f o r the community a t l a r g e . fir. S., the f a t h e r of Dr. P., together with a number of other peasant farmers donated a p i e c e of l a n d f o r t h i s purpose. The d e c i s i o n to b u i l d on a s i t e a c o n s i d e r a b l e d i s t a n c e from the church compound was c r i t i c a l t o the P r o j e c t ' s development. By d e s i g n , the programme was to i n v o l v e a l l of the people i n the two s u b - l o c a t i o n s of asembo East and asembo .Best, and not only the people i n the v i c i n i t y or members of the S a r a d i d i CPK church. at one of the f i r s t p u b l i c barazas, the c h i e f of Asembq East {who i s c u r r e n t l y the Patron o f the S a r a d i d i Rural Health Development P r o j e c t ) began the f u n d - r a i s i n g d r i v e f o r the s e l f - h e l p d i s p e n s a r y by g i v i n g twenty Kenya s h i l l i n g s {in Canadian currency, approximately $3.00).. On t h a t day, the people who gathered at the baraza donated a t o t a l of 600 Kenya s h i l l i n g s to begin t h e b u i l d i n g . The scheduled work f o r the c o n s t r u c t i o n of the mud-and-*wattle dispensary b u i l d i n g was subsequently o r g a n i z e d . , V i l l a g e r s donated s a p l i n g poles aud t h e i r time and c o o p e r a t i v e e f f o r t i n the a c t u a l c o n s t r u c t i o n of the b u i l d i n g , with c h a p t e r s {comprised of r e s i d e n t s of the area who l i v e d and worked i n the urban c e n t r e s of K e n y a ) 1 6 donating the cement, n a i l s , timber, i r o n s h e e t s , and the payment f o r the f undyj { K i s w a h i l i f o r l o c a l c o n t r a c t o r or b u i l d e r ) . 139 Before c o n s t r u c t i o n , however, the I n t e r i m Committee — h a v i n g by t h i s time e s t a b l i s h e d i t s own autonomy from the S a r a d i d i CPK church and i t s fiural Development Committee —• i d e n t i f i e d " v i l l a g e s " t h a t could work together i n the P r o j e c t . T r a d i t i o n a l l y , there i s no such t h i n g as a " v i l l a g e " i n Luoland. * 7 F o r ; the purposes of the Project,^ however, the members o f the I n t e r i m Committee i d e n t i f i e d groups of contiguous homesteads {in Luo, dala) whpse; occupants have a " f e e l i n g of belonging together. 1* The members of t h i s l a r g e r " v i l l a g e " t r a c e t h e i r descent to the same core p a t r i l i n e a g e . , I n t h i s sense, they can be c o n s i d e r e d a segmental d i v i s o n , c l a n or dhoot ( i n Luo) of the maximal p a t r i l i n e a g e . A l t e r n a t i v e l y , when the l o c a l i z e d , t e r r i t o r i a l u n i t f o r the dhoot i s being c o n s i d e r e d — the l a n d on which they l i v e and farm — i t i s r e f e r r e d to as the gwenq.* 8 In a p h y s i c a l sense, the homesteads of a " v i l l a g e " are s i t u a t e d along the l e n g t h of a r i d g e of h i l l s , and the shambas ( K i s w a h i l i f o r gardens) of the homesteads are i n the v a l l e y s to each s i d e . Once i d e n t i f i e d , the " v i l l a g e s " were asked t o e l e c t t h e i r V i l l a g e H ealth £omgittee (VHC). R e p r e s e n t a t i v e s from each V i l l a g e H e a l t h Committee then j o i n e d t o form the Project, Committee (PC) which r e p l a c e d the I n t e r i m Committee. The Chairman, T r e a s u r e r , and Secretary o f the o r i g i n a l I n t e r i m Committee were r e - e l e c t e d t o the P r o j e c t Committee. 140 The P r o j e c t was j u s t g a i n i n g momentum through the a b l e l e a d e r s h i p of i t s Chairman. Mr. M, when he died i n October of 1979. Mr. M, who was a headmaster i n the S a r a d i d i Primary School, was r e p l a c e d by another headmster, a Mr. 0. An a d d i t i o n a l change i n the p a t t e r n of l e a d e r s h i p f o r the P r o j e c t came with the s e l e c t i o n of the E x e c u t i v e Committee. The P r o j e c t Committee, with i t s f u l l r e p r e s e n t a t i o n from a l l of the V i l l a g e H e a l t h Committees, was too l a r g e to be e f f e c t i v e i n the everyday management of the P r o j e c t . I f was decided, t h e r e f o r e , t o e l e c t r e p r e s e n t a t i v e s from the P r o j e c t Committee t o form the E x e c u t i v e Committee. T h i s Committee would be r e s p o n s i b l e to the f u l l r e p r e s e n t a t i v e body ( i . e . the P r o j e c t Committee) but' would have the a u t h o r i t y to run the everyday a f f a i r s of the programme (see F i g u r e 8 f o r a schematic diagramme of the o r g a n i z a t i o n a l s t a g e s of the P r o j e c t ) . A few months a f t e r the S a r a d i d i d i s p e n s a r y was c o n s t r u c t e d , a seminar was h e l d f o r the community l e a d e r s i n the P r o j e c t . At t h i s workshop, the l e a d e r s were i n s t r u c t e d t o l i s t i n order of p r i o r i t y the concerns t h a t they had f o r t h e i r own " v i l l a g e s . ' ? * 9 They were then a d v i s e d by r e s o u r c e people from the A f r i c a n Medical and Research Foundation (AMREF), the Department of Community Health ( U n i v e r s i t y of N a i r o b i ) , and the United Nations I n t e r n a t i o n a l C h i l d r e n ' s Emergency Fund (UNICEF), how to e f f e c t i v e l y address these f e l t - n e e d s through the s t r u c t u r e of CBHC. Subsequent t q F i g u r e 8. The O r g a n i z a t i o n a l Development o f the S a r a d i d i Rural H e a l t h Development P r o j e c t P r o j e c t Committee (PC) E x e c u t i v e Committee (EC) V i l l a g e H e l p e r s 3 S Towards H e a l t h (VHsTH) V i l l a g e H e a l t h Committees (VHCs) I n t e r i m Committee (IC) 1 Rural Development Committee (RDC) ( S a r a d i d i CPK Church) The o r g a n i z a t i o n a l s t a g e s o f the P r o j e c t are numbered i n the sequence o f t h e i r development 142 t h i s workshop, the P r o j e c t Committee e l e c t e d f i v e , f u l l - t i m e , s a l a r i e d workers f o r the S a r a d i d i Centre: a £EQject lanaqe r , Community fiurse, Srpundsffla.n. and iatchman. The f i r s t group of v o l u n t e e r s Community Health Workers were t r a i n e d (named V i l l a g e Helpers Towards H e a l t h ) , and the S a r a d i d i Centre was u n o f f i c i a l l y opened i n August o f 1980. 3.3*2 A D i s c u s s i o n o f the I n i t i a t i o n of the S a r a d i d i S u r a l Health Development P r o j e c t [SBHDP) 3-3-2.1 "Community" over "Church" I t i s evident from the preceding c h r o n i c l e of events t h a t the o r i g i n s of the P r o j e c t can be a t t r i b u t e d t o the d i s c u s s i o n s between (i) c l a n and church l e a d e r s themselves, and subsequently, i n more s p e c i f i c c o n s u l t a t i o n s with [ i i ) Dr. P and the two medical s t u d e n t s . I n i t i a l l y , the d i s c u s s i o n s r e g a r d i n g a community-based programme arose i n the context of the c h urch, but as time progressed, t h e r e was a d e l i b e r a t e a b r o g a t i o n of these s p e c i f i c o r i g i n s [ i . e . i n the church) and a c o n s c i o u s attempt t o t r a c e the o r i g i n s of the P r o j e c t to the c o l l e c t i v e "community." I f t h e r e i s one theme that c h a r a c t e r i z e s the conceptual p r o c e s s i n v o l v e d i n the c o n s t r u c t i o n of the SfiHDP, i t i s the commitment on the p a r t of P r o j e c t l e a d e r s t o "break the t i e s of church and c l a n " and i n v o l v e the people i n a "community" e f f o r t . So s u c e s s f u l has t h i s e f f o r t been i n overcoming c l a n , church, i n d i v i d u a l , and f a m i l y d i f f e r e n c e s , t h a t many of the c u r r e n t 143 r e p r e s e n t a t i v e s on the E x e c u t i v e Committee deny any o r i g i n a l o r c u r r e n t a s s o c i a t i o n with the church. " T h i s i s a community p r o j e c t , not a church p r o j e c t , " they r e p e a t e d l y say. No one i n d i v i d u a l or group i s given the honour f o r t h i s c r e a t i v e urge, but r a t h e r , the community of combined l e a d e r s i n the area of S a r a d i d i i t s e l f . 3.3-2.2 Two Types of Leaders Nevertheless, t h e r e emerges at t h i s i n i t i a l stage a typology of l e a d e r s i n v o l v e d i n the c o n c e p t u a l i z a t i o n of the P r o j e c t . There are the t r a d i t i o n a l , clan-based l e a d e r s {in Luo, j o d o n g o ) 2 0 whose a u t h o r i t y r e s t s on " g e n e r a t i o n a l " s t a t u s w i t h i n the l i n e a g e , 2 1 and t h e r e are the " p r o f e s s i o n a l " l e a d e r s whose a u t h o r i t y i s d e r i v e d from " s o c i o - e c o n o m i c " 2 2 c o n s i d e r a t i o n s . Both s t r u c t u r e s of l e a d e r s h i p and a u t h o r i t y are c u r r e n t l y o p e r a t i v e i n Luo s o c i a l l i f e ; and i n the case of the i n i t i a t i o n o f the S a r a d i d i S u r a l Health Development P r o j e c t * both groups of l e a d e r s played a s i g n i f i c a n t part., I t i s a merging of t h e i r combined i n t e r e s t s , i n t e n t i o n s , and a u t h o r i t y t h a t has c o n t r i b u t e d t o the making of the SRHDP an a u t h e n t i c a l l y "community-based" P r o j e c t . The r e s u l t of t h i s cooperative, e f f o r t has seen the emergence of a t h i r d type of community l e a d e r . The Community H e a l t h Workers [or V i l l a g e Helpers Towards Health) b r i d g e t r a d i t i o n a l and p r o f e s s i o n a l a u t h o r i t y s t r u c t u r e s , and symbolize the c r e a t i o n of an i n n o v a t i v e and a m e l i o r a t i v e s o c i a l o r d e r . 144 3.3.2.3 The P r o j e c t i n R e l a t i o n t o Harambee P r o j e c t s Since t h e r e e x i s t s t h i s involvement and c o o p e r a t i o n between both types of l e a d e r s [ t r a d i t i o n a l and p r o f e s s i o n a l ) , the o p p o r t u n i t y was given f o r the c r e a t i o n of a CBHC programme i n v o l v i n g CHWs. I t should be s t a t e d * however, t h a t the pr o c e s s of developing the SBHDP occur r e d i n response to a l a r g e r , p o l i t i c a l r e a l i t y ; i . e . , the experience of government i n a c t i o n and i n e f f e c t i v e n e s s . A mi n o r i t y of l e a d e r s were of the o p i n i o n t h a t i f the community c o n s t r u c t e d i t s own harambee d i s p e n s a r y , the M i n i s t r y of Health would e v e n t u a l l y t a k e over the Project»s a d m i n i s t r a t i o n and r e s p o n s i b i l i t y f o r f i n a n c i n g s a l a r i e s , drugs, and maintenance c o s t s . On the other hand, the ma j o r i t y of l e a d e r s b e l i e v e d t h a t the M i n i s t r y of Health would: never get i n v o l v e d . In f a c t , they p r e f e r r e d the government to stay out of the P r o j e c t so t h a t i t c o u l d always remain a community a f f a i r . The view o f l e a d e r s with t h i s p o l i t i c a l p e r s p e c t i v e , was that the government would continue t o a l l o c a t e the bulk of i t s h e a l t h . c a r e r e s o u r c e s t o the urban areas, and f o r t h i s reason, they would be f o r c e d to manage the problem on t h e i r own. 2 3 F o r t u n a t e l y , s i n c e they had the e x p e r t i s e and commitment of Dr. P and the othe r two medical s t u d e n t s , there would be no b a r r i e r s t o the accomplishment of t h i s g o a l . I t would remain — i n the eyes of community l e a d e r s — a community and not a government-inspired [harambee) p r o j e c t . 145 N e v e r t h e l e s s , d u r i n g the f u n d - r a i s i n g baraza ( p u b l i c meeting), the a c t u a l a c t i v i t i e s were c h a r a c t e r i s t i c of the f a m i l i a r harambee event but with the a d d i t i o n a l element of t r a d i t i o n a l Luo c o m p e t i t i v e r i v a l r y , Sisungore (Luo f o r they boast) i s a way o f r e f e r r i n g t o the c o m p e t i t i v e d i s p l a y between r i v a l l i n e a g e groups. During t h i s baraza which was s p e c i f i c a l l y c a l l e d f o r the r a i s i n g of money f o r the b u i l d i n g of the c l i n i c , the Chairman of the SBHDP c r e a t e d a c o n t e s t between the two s u b - l o c a t i o n s of Asembo E a s t and Asembo West. Sums o f money were r a i s e d c o m p e t i t i v e l y I q i s u n g o r e ) 2 4 between these two r i v a l groups over the span, o f a few hours. 3.3.2.4 The Need f o r C l i n i c a l S e r v i c e s The i d e a of "community-based h e a l t h c a r e " (CBHC) was s e i z e d by the people of Asembo East and West as an e v e n t u a l i t y which symbolized new p o s s i b i l i t i e s f o r development. As a model f o r change t h a t addressed a broad range of "unmet f e l t needs," i t was a l s o l e g i t i m i z e d i n t h a t i t transcended c l a n , church, and government i n t e r e s t s . These p a r t i s a n and s e c t a r i a n a s s o c i a t i o n s i n the Luo. community tended to fragment community members and d e t e r them i n t h e i r a b i l i t y t o cooperate i n development programmes. Yet from the very b e g i n n i n g , everyone i n the P r o j e c t area c o u l d agree on the need f o r a c l i n i c . T h i s was t h e i r 146 primary i n c e n t i v e and the symbolic f o c u s f o r t h e i r involvement i n the S a r a d i d i R u r a l Health Development P r o j e c t (SRHDP). Before V i l l a g e Helpers Towards He a l t h (VHsTH) c o u l d be t r a i n e d f o r purposes of communicating d i s e a s e p r e v e n t i o n and h e a l t h promotion knowledge, a c l i n i c would have to be b u i l t t h a t o f f e r e d c l i n i c a l h e a l t h care s e r v i c e s . 2 5 The b u i l d i n g of the S a r a d i d i c l i n i c symbolized t h e i r p e r c e p t i o n of what the P r o j e c t would o f f e r and t h e i r d e s i r e t o have and a t t a i n the modern h e a l t h care conveniences t h a t other people i n the D i s t r i c t e n j o y e d . 2 6 3.4 THE SOCIAL ORGANIZATION OF THE SARADIDI RURAL HEALTH DEVELOPMENT PROJECT (SRHDP) The work was s t a r t e d , by the community; The p r o j e c t i s b e i n g c a r r i e d , fey. th§. community; The workers are p a i d f o r , by the • community; The l a n d was g i v e n , fey. the community ! ( T r e a s u r e r , E x e c u t i v e Committee, SRHDP).; From the d i s c u s s i o n o f events t h a t l e d to the development and o r g a n i z a t i o n of the SRHDP (see F i g u r e 9) , i t i s e v i d e n t t h a t the P r o j e c t i t s e l f was c r e a t e d i n response t o a r e c o g n i z e d need i n the a r e a . The government, i t was f e l t , was not p r o v i d i n g e f f e c t i v e and proximate s e r v i c e s to the people i n S a r a d i d i . The n e a r e s t H o s p i t a l s e r v i c e s were at Siaya [30 k i l o m e t r e s away), and there was no ambulance s e r v i c e t o handle c r i t i c a l cases. I t was decided t h a t i n order to address these s e r i o u s F i g u r e 9. S o c i a l O r g a n i z a t i o n o f the S a r a d i d i Rural H e a l t h Development P r o j e c t E x t e r n a l O r g a n i z a t i o n s S a r a d i d i Rural H e a l t h Development P r o j e c t Department o f Community H e a l t h , U n i v e r s i t y o f N a i r o b i Funding Agencies (eg. FPIA) M i n i s t r y o f H e a l t h and Non-Government O r g a n i z a t i o n s V o l u n t e e r O r g a n i z a t i o n P r o j e c t D i r e c t o r P r o j e c t Manager Community Nurse V o l u n t e e r E x e c u t i v e Committee P r o j e c t Committee V i l l a g e H e a l t h Committees V i l l a g e H e l p e r s towards H e a l t h (VHsTH) • V i l l a g e s A s c h e m a t i c diagramme o f the a d m i n i s t r a t i o n and s o c i a l o r g a n i z a t i o n o f the SRHDP which i n d i c a t e s the r e l a t i o n s h i p s o f r e s p o n s i b i l i t y and a c c o u n t a b i l i t y between a c t o r s and groups i n v o l v e d i n the P r o j e c t . 148 problems, a CBHC programme would be i n i t i a t e d . , T h i s was i n p r i n c i p l e the agreement e s t a b l i s h e d by community l e a d e r s (jodongo) i n c o l l a b o r a t i o n with the p r o f e s s i o n a l l e a d e r s i n the area (the p h y s i c i a n , medical st u d e n t s , headmasters, t e a c h e r s , and businessmen). While the newly e l e c t e d P r o j e c t D i r e c t o r (Dr. P) hoped f o r the development of a CBHC programme that would emphasize di s e a s e p r e v e n t i o n and h e a l t h promotion a c t i v i t i e s , the ma j o r i t y of l e a d e r s ( r e p r e s e n t i n g the o p i n i o n of household heads i n t h e i r v i l l a g e s ) were adamant i n t h e i r d e s i r e t o c o n s t r u c t a c l i n i c p r o v i d i n g c u r a t i v e s e r v i c e s . Because of t h i s o v e r r i d i n g consensus t o b u i l d a s e l f - h e l p d i s p e n s a r y , the P r o j e c t D i r e c t o r went along with the l e a d e r s on the P r o j e c t Committee. From the very beginning, t h e r e f o r e , evidence was given of the a b i l i t y of t r a d i t i o n a l and p r o f e s s i o n a l l e a d e r s to cooperate i n the development of the P r o j e c t . N e v e r t h e l e s s , while the d i v i s i o n s between c u r a t i v e and pr e v e n t i v e o r i e n t a t i o n s posed p o t e n t i a l development prob-lems, a d d i t i o n a l s t r a i n s were beginning t o s u r f a c e with the i n t r o d u c t i o n of income-generating p r o j e c t s . The V i l l a g e H e l p e r s Towards H e a l t h (VHsTH) who i n c o r p o r a t e d i n t h e i r p o s i t i o n the t e n s i o n s between t r a d i t i o n a l and p r o f e s s i o n a l i n t e r e s t groups bore the brunt of these emerging d i f f i c u l t i e s . I t c e n t r e d on the problem of money. Should those persons who a r e s e l e c t e d and e l e c t e d t o work i n v a r i o u s c a p a c i t i e s i n the P r o j e c t work as v o l u n t e e r s or 149 sh o u l d they r e c e i v e a s a l a r y ? Of a l l the i s s u e s t h a t threatened t o c r i p p l e the s u s t a i n e d involvement of community members i n the S a r a d i d i S u r a l Health Development P r o j e c t (SRHDP), t h i s i s s u e was p o t e n t i a l l y the most s e r i o u s . Yet while these t e n s i o n s were c h a r a c t e r i s t i c o f the day t o day a c t i v i t i e s i n the P r o j e c t , there was a comp e l l i n g f o r c e t o accomplish c o l l e c t i v e and communal order. P e r s o n a l , i n d i v i d u a l , l i n e a g e , r e l i g i o u s , p o l i t i c a l , and p r o f e s s i o n a l i n t e r e s t s were subsumed under the canopy of community i n t e r e s t s , g o a l s , and o b j e c t i v e s . In t h i s s e c t i o n , I c o n c e n t r a t e on the o r g a n i z a t i o n a l s t r u c t u r e t h a t developed i n the c o n s t r u c t i o n of the SRHDP and the experience o f these f o l l o w i n g i n d i v i d u a l s and groups: the Exe c u t i v e Committee (EC), the V i l l a g e H e a l t h Committee