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

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EPISTEMOLOGICAL  RELEVANCES  IN COMMUNITY-BASED HEALTH CARE PROGRAMMES IN THE REPUBLIC OF KENYA By DENNIS GEORGE WILLMS B.A. (Honours), U n i v e r s i t y M.A.,  of W a t e r l o o ,  McMaster U n i v e r s i t y ,  A THESIS SUBMITTED  1972  1975  IN PARTIAL FULFILLMENT OF  THE REQUIREMENTS FOR THE DEC-REE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE STUDIES Department  We  of Anthropology  accept t h i s  thesis  to the r e q u i r e d  and S o c i o l o g y  as conforming standard  THE UNIVERSITY OF BRITISH COLUMBIA April (c)  1984  Dennis George Willms, 1984  In p r e s e n t i n g requirements  this thesis f o r an  of  British  it  freely available  for  understood that for  Library  shall  for reference  and  study.  I  f o r extensive copying of  h i s or  be  her  g r a n t e d by  f i n a n c i a l gain  shall  not  be  of  A n t h r o p o l o g y and  The U n i v e r s i t y o f B r i t i s h 1956 Main Mall V a n c o u v e r , Canada V6T 1Y3  Date  DE-6  (3/81)  A  p  r  i  l  2 i t  1  9  8  A  Sociology  Columbia  make  further this  thesis  head o f  this  my  It is thesis  a l l o w e d w i t h o u t my  permission.  Department o f  the  representatives.  copying or p u b l i c a t i o n  the  University  the  s c h o l a r l y p u r p o s e s may by  the  I agree that  permission  department or  f u l f i l m e n t of  advanced degree a t  Columbia,  agree t h a t  in partial  written  ABSTRACT  This  dissertation  •community-based three  separate  idealistic  by WHO  Republic  reflect This  health  model  propounded the  health  health  of  care  the  CBHC  care  constructed  of  how  to  health  organizations i n  of t h e i r  these  predicated  the  care*)  CBHC programmes  and r e l e v a n c e s  care  that  situation.  epistemological on  organizational  non-government,  context,  differences  health  workers,  care  and  between:  economic standards. on a  (harambee:  and economic  urban/rural  influences,  and  The M i n i s t r y  of  n a t i o n a l CBHC programme  an e m p h a s i s  on s e l f - h e l p  ( a i d - r e l a t e d monies)  constraints.  inflexibility  of biomedicine  an  salaried/volunteer  modern/traditional  political  strategy;  t h e e v e n t o f CBHC h a s  resources,  h a s embarked  bureaucratic  culture  relation  'primary  government,  health  (Case 1)  development)  In  health  CBHC a r e  complex/subsistence  because o f  problem  programmes.  the  allocation  Yet  have  in  t h e Kenyan  accentuated  (or  demonstrates  considerations independent  domains.  a n d UNICEF,  towards  the  (CBHC) a s i t i s i n t e r p r e t e d i n  CBHC  the contingencies  differences  Health  care* care  for  o f Kenya  thesis  In  examines  and  entrenchment  c a u s e i t t o be i n d i r e c t l y  consequently,  - i i-  i t i s proving  i n the  opposed t o to  be an  ineffective  instrument  programmes.  Community  Development  Project  in  the  development  of  CBHC  l e a d e r s i n the S a r a d i d i R u r a l  (Case  2)  have  assumed  a  Health  competitive  posture  i n response  t o government n e g l e c t i n t h e d e v e l o p m e n t  of  health care  infrastructure  the  the c o n s t r u c t i o n (CBHC  and  deliberately  of a  separated  control,  furthermore,  Luo  social  the  Nangina Community. H e a l t h  institutions  Community  Health  organization  has s t r e n g t h e n e d  that  •revival*  in  revitalization Relative  (CHHs) ....  i s  position  the  CBHC  is  social  Community word,  with  clan-based  impetus f o r  on  emergence  the  in  refracted Workers  These  the  of c a r e . the  i n the (CHHs).  encompasses t h e  s i t u a t i o n s appreciate.,  of  spiritual  organizations,  health care goals that  this  of health  expressed  are  Health  external  representative  institutions  social  t h a t emerge  i n one  t r u t h s and c o n c o m i t a n t  predicated  separate  with  t o the  in  expatriate  The p h i l o s o p h y  and  of traditional  o f CBHC  these  i s  area,  epistemologies  of  (CCGs).  effort.  3),  their  The  attributed  Groups  emerged  •Horthwhileness,'  have  of t r a d i t i o n a l  have c o o p e r a t e d  Workers  t o these  of  (Case  a c t i v i t i e s of  the  programme they  this  a n d most i m p o r t a n t l y ,  o f CBHC  has  Programme  the  C h r i s t i a n Community care  projects),  the r e v i t a l i z a t i o n  m i s s i o n - h o s p i t a l communities  support  Through  t h e m s e l v e s from e x t e r n a l i n t e r f e r e n c e  and  g r o u p s who  area.  comprehensive development  income-generating  health care agencies,  in their  relative  CHHs i n e a c h images  of  worthwhileness are v a r i e d , organization character Health),  i n which  i s  and r e f l e c t  they  symbolized  work; in  the r e a l i t i e s  their  phenomenological  professional  progressive  (Saradidi) ,  total situation  o f CBHC  and  o f the  [Ministry  spiritual  Of  [Sangina)]  metaphors. The  encompasses  these  •community-based  separate,  organizational  yet  i s explained  these  i n turn  Republic  impinging  h e a l t h c a r e . ' The  b e t s e e n programmes epistemologies;  i n the  in  of  Kenya  o r g a n i z a t i o n s of  difficulties  that  terms of these  emerge  differing  are i n t e r p r e t e d i n r e l a t i o n  relevances.  - iv -  to  TABLE OF CONTENTS  ^SSXfi&OjT  • .• . •  • . • • • • • •• * • - *  • XX-.  LXST OF FIGURES * • • • • • • # • * • ABBBEvTATIOHS ....... JPR£F&C£ • • *  . . . *  V  . .. - . . . •  • .•  • . • XX  Chapter I.  page  INTRODUCTION  . . . . .. .......  .. . . . .  ........ .  1  The A n t h r o p o l o g i c a l P r o b l e m . . . . . . . . . . 1 The L a n g u a g e , S y m b o l i s m , and C u l t u r e o f "Community-Based Health Care" . . . . . . 5 D e f i n i t i o n s and P r o p o s a l s o f WHO and UNI CEP . . . . ...... . . • • „• • . . , • » . 5 Problems I d e n t i f i e d i n the Implementation and Management o f CBHC Programmes ....... 10 The I m p i n g i n g S i t u a t i o n o f t h e 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 a s a H e a l t h C a r e D e v e l o p m e n t Strategy . . . . . . . . . . . . . . ........ 18 The "Harambee" Movement . . . . . . . . . . . 19 The C u r r e n t P o l i t i c a l , S o c i a l , and E c o n o m i c S i t u a t i o n i n The R e p u b l i c o f K e n y a ; P r o b l e m s o f " D e v e l o p m e n t " ....,23 Harambee, D e v e l o p m e n t , and CommunityBased H e a l t h Care; S i m i l a r Problems o f S u p p o r t , M e d i a t i o n , and I n v o l v e m e n t . . . . . . . „..,„. . .... . . . 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 o f CBHC Programmes i n Kenya ..,.,30. Complex, S u b s i s t e n c e , and P e a s a n t 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 x u G J3 H Q • • . • » . • * • * . 35 R e l a t i o n s h i p s , S t r u c t u r e s , and E v e n t s i n Ethnographic Explanation . . . . . ...,38 P e r s o n , I n d i v i d u a l , and I n d i v i d u a l i t y . . . .42  - 'v -  II.  THE PROBLEM OF COMMUMITY-BASED HEALTH CARE": THE CASE OF THE MIHISTRY OF HEALTH, REPUBLIC OF KEMYA . . . . . . . . . . . .... . . 53 M  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 o f an I n f o r m a l "Community-Based H e a l t h C a r e " P o l i c y . . . 5 9 The B u r e a u c r a t i c C o n t e x t . . .............. ,. . . 59 A C h r o n i c l e o f P l a n n i n g and P o l i c y E v e n t s i n the Process of Conceptualizing Community-Based H e a l t h C a r e . . . 66 P r o p o s a l f o r t h e Improvement o f R u r a l H e a l t h S e r v i c e s and t h e Development o f 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 i n Kenya . . . . . 66 The D e v e l o p m e n t P l a n : 1979-1983 . . . . . 68 Integrated a u r a l Health Services Programme . . . . . . . . . . . . . 70 I n t e r n a t i o n a l C o n f e r e n c e on P r i m a r y Healthcare . . . . . . . . . . . . 72 An I n t e g r a t e d S u r a l H e a l t h and F a m i l y P l a n n i n g Programme (IRH/FP) . . .,..73A Review o f t h e C o n c e p t u a l P r o c e s s i n t h e F o r m u l a t i o n o f "Community-Based Health Care" .. - .74 The S o c i a l O r g a n i z a t i o n o f an " E x p e r i m e n t a l " Community-Based H e a l t h C a r e Programme . . 79 F o r c i n g t h e I s s u e o f Community-Based Health 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 " 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 " (FHFE) Programme 84. Proposal f o r the Organization of a N a t i o n a l "Community-Based H e a l t h C a r e " Programme . . . . . . . . . . . . . 86 The S h i f t i n g Paradigm . . . . . . . . . .87 P r o p o s e d C e n t r a l and D i s t r i c t L e v e l Organization . . . . . . . . . . . . 89 Proposed Organization a t the "Community" L e v e l . . . . . . . . . 92 The Community H e a 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 Health's O r g a n i z a t i o n a l Scheme f o r Community-Based H e a l t h C a r e (CBHC) ..,,,96. The Management o f a N a t i o n a l Community-Based H e a l t h C a r e Programme . . . . . . . . . . 100 Management P r o b l e m s i n t h e P i l o t P r o j e c t ;  Discussion o f the Ministry of Health's Management P r o b l e m s i n CommunityB a s e d H e a l t h C a r e (CBHC) . . . . . .  - vi -  104  D i s c u s s i o n o f 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 o f "CommunityBased H e a l t h C a r e " . ............. . . .. . A Review o f t h e E p i s t e m o l o g i c a l Dilemma . . A C r i t i c a l Problem i n the Implementation o f a Government "Community-based H e a l t h C a r e " Programme . .... . . . . . III.,  THE SABADIDI BUBAL HEALTH DEVELOPMENT PROJECT: THE CASE OF AH INDEPENDENTLY CONSTRUCTED CBHC PROGRAMME . . . . . . . . . . . . . . I n t r o d u c t i o n . . . . ,. . . . . . . . . . . . . . . Settxng . . . . . . ... . . ... ... ... C l i m a t e and E n v i r o n m e n t . . . . . . . . . . . P o p u l a t i o n and H e a l t h Needs . . . . . . .... . 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 o f t h e 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) . . . . . . ... . . . . A C h r o n i c l e of P r o j e c t E v e n t s . . . . . . . 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 H e a l t h Development P r o j e c t (SRHDP) . . . . . . . . . .. . "Community" o v e r " C h u r c h " . . . . . . . Two T y p e s o f L e a d e r s . . . . . . . . . . The P r o j e c t i n R e l a t i o n t o Hjarambee Projects . . . . . . . . . . . . . The Need f o r C l i n i c a l S e r v i c e s . . . . . The S o c i a l O r g a n i z a t i o n o f t h e 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) . . . . . . . . . . . . . . ...... The E x e c u t i v e Committee (EC) . . . . . . . D e s c r i p t i o n and F u n c t i o n o f t h e E x e c u t i v e Committee (EC) . . . .... The E x p e r i e n c e o f E x e c u t i v e Committee Members i n t h e 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 . . . . The I n i t i a t i o n o f Income G e n e r a t i n g Projects . . . . . . . . . . . . . Epistemological Issues . . . . . . . . . The V i l l a g e H e a l t h C o m m i t t e e s (VHCs) . . . D e s c r i p t i o n and F u n c t i o n o f t h e V i l l a g e H e a l t h Committee . . . . . The R e l a t i o n s h i p t o t h e E x e c u t i v e Committee (EC) . . . . ... . . . . . The R e l a t i o n s h i p t o t h e V i l l a g e H e l p e r s Towards H e a l t h (VHsTH) . . Problems of Development: Health Care Knowledge or I n c o m e - G e n e r a t i n g Projects . . . . . . . . . . . ...... The P r o j e c t D i r e c t o r (PD) . . . . . . . . . The F u n c t i o n o f t h e 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 Rural Health Development P r o j e c t . . . . . ....... - vii -  106 106 10*  122 122 123 128 132 133 134 142 142 143 144 145 146 149 149 152 155 157 160 160 163 164 165 166 166  The E x p e r i e n c e of t h e P r o j e c t D i r e c t o r W i t h i n and W i t h o u t t h e S a r a d i d i Community . . . . .. . • . . .. The P o s i t i o n o f L e a d e r s i n t h e D e v e l o p m e n t o f Community-Based H e a l t h C a r e : The S i t u a t i o n o f S a r a d i d i . . .. . . . . . . . . .. . The V i l l a g e H e l p e r s T o w a r d s H e a l t h £ VHsTH) . . . . . . . ................. Naming t h e Community H e a l t h Worker . . . S e l e c t i o n and T r a i n i n g o f V i l l a g e H e l p e r s Towards H e a l t h (VHsTHJ . . A c t i v i t i e s of the V i l l a g e Helper Towards H e a l t h i n the V i l l a g e and a t t h e C l i n i c . . . . . . . . T r a d i t i o n a l or P r o f e s s i o n a l Orientations: The Dilemma o f t h e V i l l a g e H e l p e r s Towards Health . . . . . . . ,. . . . . . ... 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 H e a l t h Development P r o j e c t (SRHDP) . . . . . ..... . . 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 o f an I n d e p e n d e n t Community-Based H e a l t h C a r e Programme . I d e n t i f i c a t i o n o f Needs i n t h e Community . The C r e a t i o n o f Community: The O r g a n i z a t i o n a l Response . . . . . . . Epistemological Considerations . . . . . . . . . IV.  NANGINA COMMUNITY HEALTH PROGRAMME: THE CASE OF CBHC IN THE ENVIRONS OF A MISSION HOSPITAL . . . . . . . . . Introduction . . . . . ... . . . . . . 3 61 ^> i xi (j • •.•,» •_••.».• C l i m a t e and E n v i r o n m e n t . . . . . . . . . . P o p u l a t i o n and H e a l t h Needs . . . . . . . . The C o n c e p t u a l P r o c e s s i n t h e C o n s t r u c t i o n o f N a n g i n a ' s Community-Based Health C a r e (CBHC) Programme . . . . . . . ....... Nangina H o s p i t a l ...... • • • . • ....„-., Towards t h e F o r m a t i o n o f " P u b l i c H e a l t h Committees" i n t h e Community . . . . . . . . . . . . The N u t r i t i o n A i d e F i e l d Worker (NAFW): A worker i n t h e Community ... . . . . . . . . . . . C h r i s t i a n Community G r o u p s (CCGs) a s a V e h i c l e f o r Community-Based H e a l t h c a r e (CBHC) . . . . . . . . The C o n s t r u c t i o n o f t h e CBHC Alternative: A Summary o f E v e n t s a t Nangina H o s p i t a l . . . . v-Wi  -  169  172 175 175 176; 177  180 184 187= 188 189 191  203 203 207. 207 209 212 213 214 216 218  219  N a n g i n a M i s s i o n . . . . . . . . . . . . . . 221; C h r i s t i a n Community Groups (CCGs) . . . 222 Community H e a l t h Workers (CHWs) . . . . 223 F a t h e r N a n d t h e C o r e Group . . . . ........ 225 " L i f e i n t h e S p i r i t " Seminars . . . .,. . 226 The S p i r i t u a l and C o n c e p t u a l T r a n s f o r m a t i o n o f Nangina M i s s i o n and P a r i s h : A Summary o f the Construction o f C h r i s t i a n Community G r o u p s [CCGs) . ,.. . . . 227 The S o c i a l O r g a n i z a t i o n o f N a n g i n a ' s Community-Based H e a l t h C a r e [CBHC) Programme . . . . . . . * . . . . . . . 230 N a n g i n a H o s p i t a l and t h e Community H e a l t h W o r k e r s (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 / F a m i l y P l a n n i n g ) 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 E x p e r i e n c e o f Community H e a l t h Worker T r a i n e r s / S u p e r v i s o r s a t Nangina Hospital: A Summary S t a t e m e n t . . 239 N a n g i n a M i s s i o n and t h e Community H e a l t h *  Ho.xrfc6ir*5  •  •• . • , . • • • . • . . » , •  • .  N and t h e Community H e a l t h W o r k e r s (CHWs) . ....... . . . . . . The P a r i s h C o u n c i l and t h e Community H e a l t h Worker . . . . . . ... . . . The R e l a t i o n s h i p o f N a n g i n a M i s s i o n ( t h e P r i e s t and Members o f t h e P a r i s h C o u n c i l ) t o t h e Community H e a l t h Workers; A Summary Statement . . . . . . . . . . . . C h r i s t i a n Community G r o u p s (CCGs) and t h e i r Community H e a l t h Workers (CHWs) • . . • • ............... L e a d e r s h i p i n t h e C h r i s t i a n Community G r o u p s (CCGs) . . . . . . . . . . S o c i a l Features of the C h r i s t i a n Community G r o u p s (CCGs) . . . . . . A c t i v i t i e s o f t h e C h r i s t i a n Community G r o u p s (CCGs) . . . . . . . . . . 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 Organization of the C h r i s t i a n Community G r o u p s (CCGs): A Summary S t a t e m e n t . ,. ,. Community H e a l t h Workers (CHWs) . . . . . . Selection . . . . . . . . . . . . . . . . . Training . . . . . . . . . . . . . . . . . . Activities . . . . . . . . . . . . . . .  ^  Father  -  i'X- -  244. 246  247  249 252 254. 258  259 262 262 263 265  P r o b l e m s E n c o u n t e r e d by t h e Community H e a l t h Worker ... . . . . .. . . . The Community H e a l t h w o r k e r ' s Experience of Support . . . . ....... An E p i s t e m o l o g i c a l P r e d i c a m e n t : A Summary S t a t e m e n t o f t h e Community H e a l t h Worker's S o c i a l Situation . . . . .. . • • . • • • 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 o f t h e N a n g i n a CommunityBased H e a l t h C a r e Programme . .. . . . . I d e n t i f i c a t i o n o f Needs: . . . . . . . . . S y m b o l i c E v e n t s and E p i s t e m o l o g i c a l Relevances . . . . . . . . . . . . .,. The T o t a l S i t u a t i o n . . . . . . . . . . . . . . ¥..,.  CONCLUSION  . . . .  . ..  . . . . . . . . . . . . . . . . . .  - x  273  275 279 282 284 288 301  Introduction . . . . . . . . . . . . . . . . . The " E v e n t " o f "Community-Based Health Care" [CBHC) . . . . . . . . . . . . . . . . . Structural Considerations . . . . . . . . . . E s p i s t e m o l o g i c a l R e l e v a n c e s a n d Community H e a l t h Worker S i t u a t i o n s . . . . . .... . Conclusion . . . . . . . . . . . . . . . . . . . BIBLIOGRAPHY  271  . . .  301 303 304 309 315 319  L I S T OF  FIGURES Title  Figure  1.  Kenya  Figure  2.  Maternal C h i l d  F i g u r e 3.,  Site in  2 (MCH)  Clinic --  14-15  Headquarters  Nairobi  58  Kenya  Figure  Administrative the  F i g u r e 6.  Health  of M i n i s t r y of H e a l t h  F i g u r e 4. 5.  Pag_e (s)  Community  Nurse  (KCN)  Organization  M i n i s t r y of Health  Site  of S a r a d i d i Rural  Project,  64 Proposed  by  i n Kenya Health  Siaya D i s t r i c t ,  81  Development  Nyanza  Province,  Kenya  129  F i g u r e 7.  Saradidi C l i n i c  137  Figure  The O r g a n i z a t i o n a l Development o f t h e  8.  Saradidi F i g u r e 9.  Rural  Health  Development P r o j e c t  Social  Organization  Health  Development P r o j e c t  Figure  10.  Members o f E x e c u t i v e  Figure  11.  Community  Figure  12.  Site Busia  Health  of t h e S a r a d i d i  Committee  Workers  Rural 147  [EC)  (CHWs)  o f N a n g i n a Community H e a l t h District,  141  150 178  Programme,  Western P r o v i n c e ,  Kenya  Figure  13.  Nangina H o s p i t a l  Figure  14.  The O r g a n i z a t i o n a l D e v e l o p m e n t o f t h e  208 211  N a n g i n a Community H e a l t h xi -  Programme  215  Figure  15.  S o c i a l o r g a n i z a t i o n of the Nangina Health  Community  Programme  232  Figure  16.  Community  Health  Worker  (CHS) T r a i n e r  Figure  17.  Community  Health  Worker  (CHW)  Meeting  240-1  Monthly 267  - - -'Xii.i —  ABBREVIATIONS  AMREF  A f r i c a n M e d i c a l a n d fiesearch F o u n d a t i o n (incorporating East African Flying Doctor Services)  CBHC  Community-Based  CCGs  Christian  Community G r o u p s  CHWs  community  Health  CHW-SU  Community H e a l t h sponsored)  CPK  Church  CSW  Community  DANIDA  Danish  EC  E x e c u t i v e Committee  (Saradidi)  FHFE  Family Health F i e l d Nangina)  Educator  FPIA  Family  GOK  Government o f K e n y a  IEF  I n t e r n a t i o n a l Eye F o u n d a t i o n  IRH-FP  Integrated R u r a l Health - Family (Ministry o f Health)  Planning Services  IRHS  Integrated Rural Health Services Health)  (Ministry of  KCN  Kenya Community  MCH/FP  Maternal C h i l d Health / Family Planning o f H e a l t h , S a r a d i d i , and Nangina)  MOH  Ministry  NAFW  Nutrition  NCHP  N a n g i n a Community  Health  Care (Nangina)  Workers Worker - S u p p o r t >  Unit  (AMREF  o f t h e P r o v i n c e o f Kenya ( S a r a d i d i ) Social  Worker  (Nangina)  I n t e r n a t i o n a l Development  Agency  (Ministry  of Health,  Planning I n t e r n a t i o n a l Assistance (Saradidi) (Ministry  Nurse  o f Health) (Saradidi)  (Ministry o f Health)  of Health Aide  Field  Worker  Health - xi'i'i -  (Nangina)  Programme  (Ministry  NGO  Non-Government  organized  PC  P r o j e c t Committee  PD  Project  PHAs  Public  PHC  Primary Health f o r CBHC)  JJHDP  Rural Health Health)  Development  Project  [Ministry of  EHDP  Rural Health Health)  Development  Project  (Ministry of  RHTCs  Rural Health  T r a i n i n g Centres  SDDMS  S e n i o r Deputy D i r e c t o r o f M e d i c a l (Ministry of Health)  Services  SIDA  Swedish I n t e r n a t i o n a l Development  Authority  SRHDP  Saradidi Rural  Health  Project  UNICEF  United Fund  International Children's  US AID  U n i t e d S t a t e s Agency f o r I n t e r n a t i o n a l D e v e l o p m e n t (Ministry of Health, Saradidi)  VHCs  Village  VHsTH  Village Helpers Saradidi)  VHW  Village CHW)  WHO  World H e a l t h  Director Health  (Saradidi) (Saradidi)  Aides  Nations  Health  Health  Care  (Nangina) (the l a b e l  ( M i n i s t r y o f Health)  Development  Committees Towards Worker  used by HHO/UNICEF  [Saradidi)  Health  (used  Organization  - xlv_ -  Emergency  (nyainrerua,  interchangeably  with  PREFACE  The care'  subject  of  (CBHC) ,  be  the  (or P r i m a r y H e a l t h  necessary,  "achieving  health  interpreted  as i t  t o examine the  of  out  perspective Medical Project soon  planners "How  care  Kenya  health  a health  and  i si t  culturally  Yet  o f s o c i a l and  health  this  differences  and i n p a r t i c u l a r ,  care  organizations i n to  the  call  in  setting. the  for  Rural  focus  an a n t h r o p o l o g i c a l While  employed a s  Health  Development  headguarters, N a i r o b i , Kenya), I problems f a c e d  p o l i c y - m a k e r s were  p o s s i b l e , " they  epistemological  of applying  care  t h e CBHC  appropriate  these  care.•  (Ministry of Health that  delivery,  have responded  enough,  Anthropologist  realized  2000!"  year  t h e s i s i s t o explore  of a problem  in  for  The aim  Interestingly developed  the  strategy  o f m e a n i n g s and u n d e r s t a n d i n g s .  of health  'community-based  available  held  gloss f o r  how r e p r e s e n t a t i v e  Republic  i s currently  CBHC h a s emerged a s a s y m b o l i c  objective of this philosophies  only  Care)  health  a t t h e Alma-Ata  has b e e n i n a wide v a r i e t y  a broad spectrum  in  and  f o r a l l by  c u l t u r a l contexts,  and  i s 'community-based  As a k e y - p h r a s e made p o p u l a r  C o n f e r e n c e , CBHC to  this thesis  by  health  organizational i n  were a s k i n g :  CBHC programmes;"  care  nature.  (i) " t o i n i t i a t e (ii)  "to s o l i c i t  the  p a r t i c i p a t i o n and  (iii)  "to articulate  would e m p h a s i z e with  involvement  static  curative  care;"  members;"  t h e p l a n n e d CBHC programmes  disease  health  o f community  prevention  care  and h e a l t h  facilities  and ( i v )  —  which  promotion  providing  —  c l i n i c a l and  " t o s u s t a i n t h e s e programmes  over  time?" During t h e f i f t e e n of Health,  I was  §i£H) d i f f e r e n t information in  CBHC  given  However,  m o d e l s o f CBHC programmes.  a national  i t was  The  reflected  realities.  existing  In  philosophically  particular,  was,  and  respects,  UNICEF).  in  terms  of  Furthermore, in  could  similarly  observations  other,  model  The  CBHC  of  correspondences generated  proposal for  CBHC  community ( i n  M i n i s t r y Of  Health's  understandable and  organized These  of  organizational  epistemologies  non-government  finally  the Ministry  and  organizational  explained.  formulated.  requirements  quite  the  appropriate  CBHC programme  this  the  nonetheless,  generated be  be  the i n t e r n a t i o n a l health care WHO  relevances.  many  within  [reconstructed an  could  bureaucratic  contradicted  a g r e e d upon by  interpreted  that  organizational  managers  ( in,  On t h e b a s i s o f  emergent model f o r a n a t i o n a l  by u p p e r - l e v e l  position  felt  CBHC programme  materialized.  Health  t o study  g a t h e r e d on t h e s e CBHC programmes  an  proposed  I worked f o r t h e M i n i s t r y  the r e s p o n s i b i l i t y  case p r o f i l e s ) ,  model f o r  never  months t h a t  i f  situational of  CBHC  programmes  reflections  and  organizational-epistemological t h e problem o f t h i s  - xv "T -  thesis.  When i t came t o e x p l o r i n g t h e l i n e a m e n t s p r o b l e m , I was f a c e d w i t h one  hand,  I wanted  a methodological  t o expose t h e  programmes i n t h e R e p u b l i c  of  Kenya  of t h i s  research  dilemma.  On t h e  picture  o f CBHC  larger  (a m a c r o - v i e w ) ;  on t h e  in  other  hand, I needed  micro-view) , reflect  t o show h o w s i n g u l a r A  epistemologies  of health care that are posited  organizational  bureaucratic,  relevances  expatriate,  personal r e a l i t i e s ) .  tribal,  I f this  of t h e comparative  programmes i n t h e R e p u b l i c First  of a l l ,  accomplish  these  the  list  cases and  purposes.  Health  Project  Programme  effectively and I  (Case (Case  display the  permitted  the p r i n c i p a l  separate  study  1), 2),  l i s t of I  reduced  cases.  These  and a r e ;  the  Saradidi Rural  and  t h e Nangina  Secondly,  relationship  between  in  detail.  the Health;  Community order  to  epistemologies  w i t h i n a n d between  ethnographic focus  method to_  mission-hospital,  t o w a r d s CBHC,  3).  CBHC s t u d i e s  or  between CBHC  from a t o t a l  and manageable  organizational relevances to eliminate  a case  o f government,  (Case  decided  the  Selcting  independent approaches  Development  differences  operating at that time,  were r e p r e s e n t a t i v e  of Health  community,  i t would be p o s s i b l e t o  t o employ  t o three f a m i l a r ,  Ministry  clan,  example,  o f Kenya.  I decided  s i x t e e n CBHC programmes  [for  combined m a c r o - m i c r o v i e w o f  CBHC programmes was t o b e a c h i e v e d , e l u c i d a t e some  CBHC s i t u a t i o n s (a  programmes, This  tactic  on o r g a n i z a t i o n a l e l e m e n t s i n  (with  - x,vi i —  an e m p h a s i s  on s t r u c t u r e ,  social  relations,  construction),  and  truths predicated Since of  constraints,  economic, variables.  ks  i n this  health care. the  systematic  typological,  such,  I  have into  The e p i s t e m o l o g i c a l of  the  instead  constraints,  the other  predicated  issues of leadership,  on  revitalization movements,  methods included:  observations  made i n  Health  and  participants; reports,  statistical a r e those  a  of and  with  community  revival efforts.  gathering  observation  a t work);  and c o m p i l a t i o n  of [and  interviews  administrators. and  were  towards the  religious  leaders,  not  professional  health care  the  of  were,,  Health,  movements  in  of  qualitative  systems e l i c i t e d  participant  and t h e g a t h e r i n g  Community other  CBHC  o f programme  documents and p r o p o s a l s .  Theoretically, are  b a s e d on  community d e v e l o p m e n t  participation  for  the epistemologies  practices,  utilized  i n groups)  workers,  utilized  philosophies of  and comprehensive  information  made  bureaucratic  of t r a d i t i o n a l  fieIdwork  [singly,  of  a r e not  Ministry  predictable;  baseline  and e v e n  that are  exploration  exception  and  and t h e p h i l o s o p h y  comparisons  The c o m p a r i s o n s  epistemology. approach  i s no  i s , these  political,  social  realities.  there  that  of  awarenesses,  t h i s i s a t h e s i s on epistemology  comparison;  The  processes  the epistemologies,  on t h e s e  understanding,  with  and  brought  to  there bear  a r e three schools on  the  problem  of of  thought this  that  thesis:  phenomenology  (and  structuralism,  the  sociology  and s y m b o l i c  anthropology.  (critical,  The s o c i o l o g i s t s  persons i n s o c i e t y c o n s t r u c t symbols;  into  objectivation, separate care'  their  B e r g e r and l u c k m a n n  construction  moments  into  that  own w o r l d s o f meaning and  of constructing  programmes  dialectical)  knowledge a r g u e  internalization.  the process  (CBHC)  of  knowledge) ,.  and/or  (1966) s e p a r a t e  the three  and  of  this  process of  of  externalizatiqn,  In  this  thesis,  'community-based  the three  dialectical  1  health moments  o f 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 tests  CBHC i s  experienced  e x i s t i n g health  care  structuralism  i s  epistemological  relevances  development.  Some  r e l a t i o n s between: resources,  informative  of  in  that  influences,  anthropology  theoretical  i s utilized  Health  programmes.  to  Workers  that  are  refracted i n  one  hand, t h e s e  emerge  are  health  limit  constituted of health  care  i t s in care  workers,  emphases.  contribution explicate in  of  symbolic  the experience these  tensions,  the various  t h e p e r s o n and work o f t h e  tensions  the in  care  of  c o m p l e x / s u b s i s t e n c e economic  (CHWs)  in  emerged  allocation  Many o f t h e u n d e r l y i n g  potentialities  critically  determining  health  and c u r a t i v e / p r e v e n t i v e the  that  t h e framework  have  these issues  salaried/volunteer  Lastly,  Community  strategies,  an u r b a n / r u r a l  modern/traditional standards,  as a n ' e v e n t '  and c o n s t r a i n  three  of CBHC  d i l e m m a s , and  CBHC  programmes  CHWs.  On t h e  t h e work o f the  CHW;  on t h e o t h e r  hand,  i t i s i n the a c t i o n s ,  and  creative  can  develop i n t o e f f e c t i v e  theoretical  p o t e n t i a l of i n d i v i d u a l s that  distinction  •individual' in  and i n n o v a t i v e  that i s  CBHC programmes programmes.  ' p e r s o n * and  i si n s t r u c t i v e i nt h i s s i t u a t i o n .  F o r example,  social  orders,  •persons' d e f e r r i n g over that [Burridge they the  The,  made between  peasant s i t u a t i o n s , •betwixt-and-between*  complex  intentions,,  of the 1979)  CHWs  are compelled  t o t h e moral other;  s u b s i s t e n c e and to  a c t as  r e q u i r e m e n t s o f one s y s t e m  alternatively,  p e r s u a d e d by o t h e r  are capable of transcending  as ' i n d i v i d u a l s '  relevances  and t r u t h s ,  e x i s t i n g moral  tensions i n  work t h a t t h e y d o . •Worthwhileness'  metaphors, a n d three  contains  goals  that  case s t u d i e s .  worthwhileness that  i n one  motivate the  I n each  word  CHWs i n e a c h  case study,  programme. •closed'  of  [the  t h e CHW  in  possibilities by:  Ministry  of  of  Health);  [the  Project);  a •spiritual*  N a n g i n a Community  their  a 'professional'  worthwhileness and  of the  t h e image  of  Saradidi  Health  and r e f l e c t s the  the organization  These d i f f e r e n c e s a l s o r e f l e c t  characterized  images,  emerges e n c a p s u l a t e s t h e e p i s t e m o l o g i c a l  a w a r e n e s s e s and t r u t h s o f t h e i r s i t u a t i o n ^ position  the  a  of  the  t h e 'open*  position,  CBHC  and/or  and  are  image o f w o r t h w h i l e n e s s 'progressive'  Rural image o f  Programme).  Health  image  of  Development  w o r t h w h i l e n e s s (the  Finally, the  I  would l i k e  individuals  endeavour.  I am  impossible leaders, in  one  way  I am  thank  has  t h e s i s committee)  Joanne A l l a n with the  been and  Fellowships  twenty-one were,  particular,  I and Dan  and  Bennel,  Lucy  Dr. my  comments made For  attending  behalf, also  I  thank  acknowledge me  from  the  Tina  and  and  the  H.R.  (1980-1982).  the  friends  problem.  (members o f  (1979-1980)  I spent  question,  thank  F e h d e r a u , J o e l and Adams, P a u l  I  the  a l s o thank  critical  my  thesis  a s s i s t a n c e awarded t o  months t h a t  without  productive. colleagues  [my  of G r a d u a t e S t u d i e s , i n p a r t i c u l a r ,  Macmillan Family  Kenya  I  Office.  financial  me  greatly  during  t h e s i s preparation._  Graduate  is  support  Whittaker  and  i t is  have a s s i s t e d  this research  Elvi  this  community  Burridge  a d m i n i s t r a t i v e d e t a i l s on i n the  in  Ihiie  groups,  invaluable. Dr.  thank  t o h a v e known them.  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  The  t o many.  Kenelm  of  to  me  contribution  guidance  of t h i s  g r a t i t u d e the Faculty  supported  t o know and  for insightful  course  t o numerous  their  interpretation  Nancy W a x i e r - M o r r i s o n  the  and  i n d i v i d u a l s who  Dr.  his  contribution  during  and  honoured  for and  t h i s opportunity  the f a m i l i e s ,  or another,  sincerely  exploration  guided  a l l of  departments,  supervisor)  His  have  take  p e r s o n a l l y indebted  to l i s t  appreciated; I  who  to  experientially  many  who  Margaret Janzen,  Kenyan  made  Kaseje, Roy  and  this  and  E l a i n e F e l d m a n , and  - xx-ii -  i n the  Republic  of  rich  and  expatriate  possible; Harold  Betty Bruce  and  Shaffer, Scott.  in Nancy Pat  The  Development  Embassy  —  and  Co-Operation  i n particular as  Cecelia  possible  my  Ministry  of  financial  s u p p o r t and a s s i s t a n c e .  of  working  Medical  Health.  the President  t o thank D r s .  I  S.  g r a t e f u l t o Finn  of  the  Gjerdrum  —  I  At the Ministry  made i n the  acknowledge also  their  thank t h e O f f i c e  "Research C l e a r a n c e "  K a n a n i and  Swedish  Anthropologist  gratefully  f o ro f f i c i a l  NCST/SEC/4300.313) .  Office  (Ref.  o f H e a l t h , I would  Maneno;  I am a l s o  B e n n i k e , S t e v e a n d Ann F e t t n e r ,  No. like  personally Dr. Ingemar  G a h n s t e d t , Gene Howard, and Sam O b i e r o . During  the course  o f my  fieldwork  numerous CBHC programmes. friends rich to  who made  thank:  nyamrerua Mission (at  Mama Dan, H e n r y  Sisters,  Nangina);  G e o f f and Bailey (at  thank  Dr.  and M a t t i e  efficient  work  Finally, continuing  I n p a r t i c u l a r , I would  like  onyango  Andrew and C a s s Boddam-Whetham  a n d Dr.  Irvine Tolley  and  Konings,  (atChogoria); ( a t Maua); Huising  Sisters  Sister  Gill  Margaret Horsfield  (at Machakos).  of t h i s thesis,  Aruna  Srivastava  I would l i k e t o  foe  diligent  and  typing.  I would l i k e love  rural settings a  and F r e d e r i c k  preparation  Sue Schenk  t o t h e many  O c h i e n g , Tanga A u d i , and t h e many  N.  and G e r a l d i n e  the f i n a l  visited  S i s t e r Dr. Leda Liboon, the M e d i c a l  Father  Dorothy  Kisii); In  i n each o f these  experience.  (at S a r a d i d i ) ;  Kenya I  I am most g r a t e f u l  my s t a y  and r e w a r d i n g  in  t o thank  and f r i e n d s h i p ;  Rita, through  my w i f e , the  f o r her  disruptive  p e r i o d s of w r i t i n g , s u p p o r t and Willms, in  a  this  she  inspiration.  I am  has r e m a i n e d a To  my  parents,  profoundly grateful  venture they  have  constant source Waiter  f o r t h e i r l o v e and  not always understood;  t h e s i s t o them.  XXIVI  and  -  of  Frieda support  I dedicate  Chapter I INTRODUCTION  THE ANTHROPOLOGICAL  1-1 The  problem  of  ethnographically  PROBLEM  this  the experience  "community-based  health  popular  notion  health  organizations,  i s  and p r o c e s s  care"  increasingly care  thesis  (CBHC)  in  to of  explicate  accomplishing  programmes.  An  the culture of i n t e r n a t i o n a l  "community-based  health  care"  (CBHC) —  the  preferred  known as " p r i m a r y key-phrase and  1  situated focus  of  education family to  i n Kenya,  health  care"  informing  administrators  h e a l t h care  label  (PHC)  p o l i c y makers, committed  to  coverage f o r those  to health already  care  established  i n the  —  has  health  synonymously advanced as a care  providing  comprehensive  Yet unlike the c u r a t i v e  facilities,  prevention,  community,  CBHC  health  with  seek  to construct  "community-based conceptualized, care  and h o s p i t a l s . the  total  health  In  necessary  domains i n t h e R e p u b l i c -  (CBHC)  referrals  dispensaries,  programmes as  they  and managed i n v a r i o u s o f Kenya 1 -  and  case s t u d i e s ,  s i t u a t i o n of  care"  implemented,  three  emphasizes  promotion,  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 ,  health centres,  planners,  p e r s o n s t h e most p e r i p h e r a l l y  facilities.  towards d i s e a s e  planning  yet also  (see F i g u r e 1 ) .  I in  are health  2  Figure!.  Kenya  Adapted f r o m : The World Bank, Kenya: P o p u l a t i o n and Development ( W a s h i n g t o n , D.C.: Development Economics Department, E a s t A f r i c a C o u n t r y Programs D e p a r t m e n t , The World Bank, 1980), R e g i o n s and Districts  Map.  3 I  argue that  what  'health,'  of the the  because o f  social  notion  CBHC  in all  prominent event. or o r g a n i z a t i o n significance: acceptance  i s  with  'money'  parishioners  their  and t h e  3)  and  be  bureaucracy  the  the and  of  for  a relevant for  of  t h e emergence o f CBHC  provides self  an in  avenue f o r service  of  t o the strategy  ethnographic  the  and  the Nangina  e p i s t e m o l o g i c a l l y through  the  cases:  Ministry  an i n d e p e n d e n t ,  L u o community  Saradidi  Luo community  of  gea,lth;  i n N a i r o b i , Kenya;  situation of  peasant,  of  accomodating  three  i t s  promise  while  sense of  explained  (see Chapter 2 ) ,  the  4),  communities  of the f o l l o w i n g  the  to  strategy;  These d i f f e r e n c e s i n  CBHC i s a  and i d e o l o g i c a l  continuing  i t augurs  renewed  headquarters (2)  promise o f  political,  (see Chapter  clan-based  CBHC w i l l  (1)  possiblity,  on t h e p a r t i c u l a r community  support;  (see C h a p t e r  presentation  the  economic,  financial  actualizing  of  a  interpreted,  t o the M i n i s t r y of H e a l t h  the r u r a l  others.  perceived,  situations,  comprehensive development  in  'community' means i n e a c h  CBHC emerges as  I t breaks i n  means  aid-related  Mission  and  accordingly,  yet  Saradidi  care,*  domains where of  transformed And  'health  the differences i n understanding of  Rural  in  Health  rural-based,  t h e i r c o n s t r u c t i o n of Development  Project;  4 (3)  the experience P£29£amme ~~ and  o f the  a programme  hospital  religious  and  of  whose  modern,  facilities)  but  are  relies  Health  a  influence  mission  i s  both  (through the  clinical,  which  s y s t e m s o f community cases  i n s p i r e d by  ( C h r i s t i a n ) and b i o m e d i c a l  provision  These  Nang.in.a_ Community  health on  care  traditional  support.  significant  in  that  they  address  the  question: (i)  How i s " c o m m u n i t y - b a s e d possible?  Secondly, they the  (CBHC)  a r e s u f f i c i e n t l y d i v e r s e and u n i q u e t o answer  question: (ii)  But  What does "community-based health care" (CBHC) mean a n d how i s i t s h a p e d by t h e political economy and ideology of differentially constructed social-cultural realities?  while  evident these  the larger  this  Workers  compelled find  to  (CHWs)  --  assume t h e  2  who s u b s c r i b e  expectations, intervenes  with  cloak  and  —  i t i s the  those  of  their  own  CBHC programme.  of  the (as  s e e C h a p t e r 2) ,  —  who,  individuality either  permits  E i t h e r they a c t  t o the p r o f e s s i o n a l  statuses  t o make  Community  l i k e them  p o s i t i o n that  i t s p l a n f o r CBHC  of Health  thesis are  p r o b l e m i s p r e d i c a t e d on  For  and  the social  t h e making o f a  persons  Ministry  the specific  possibilities.  themselves i n  or deters  problems o f t h i s  process,  emerging  Health  as  health care"  requirements,  organization i n t h e case  that of the  o r i n negotiating the  5 contradictions, ensue  i n the i n i t i a t i o n  them,  and  in  participation and in  so  of  the Saradidi  doing  t h i s study.  and  resources, t h i s with  1.2  3)  i s acomplished  i s exemplified (Chapter 4). Health  i t must be so i s t h e s p e c i f i c  problem  involvement  contribution  trainers,  to develop  o f community  authentically  members and  their  o f t h e CHWs i s n e c e s s a r y — of P r o j e c t D i r e c t o r s ,  n u r s e s , and community  CULTURE OF  D e f i n i t i o n s a n d P r o p o s a l s o f H HO and  ' A recent p u b l i c a t i o n  and  by Community  THE LANGUAGE, SYMBOLISM, AND BASED HEALTH CARE"  1.2.1  transcend  This sustained  and N a n g i n a c a s e s  them t h e s u p p o r t s y s t e m  elders, leaders,  inevitably  involvement  members.  F o r CBHC programmes  with the f u l l  the  i n t h e CBHC programme  {Chapter  (CHWs) and why  problems t h a t  mobilize  o t h e r community  this articulation  Workers  and  o f d e v e l o p m e n t programmes  continuing interest  How  of  oppositions,  o f t h e WHO  indicates  and  village  members.  "COMMUNITYUNICEF that;  d e s p i t e an i n t e r n a t i o n a l l y a g r e e d d e f i n i t i o n , the term " p r i m a r y h e a l t h c a r e " i s b e i n g a p p l i e d a r o u n d the w o r l d to a v a r i e t y o f r e a l i t i e s and even o f concepts. ? This  situation  is  confirmed  s u g g e s t s t h a t an e x a m i n a t i o n CBHC programmes  are  the e p i s t e m o l o g i c a l of  these a c t i v i t i e s .  (PHC)  or  in of  implemented  our t h r e e  cases,  the processes through must be v i e w e d  care"  of  the outcome  B u t t h e n , what i s P r i m a r y health  which  in light  r e l e v a n c e s which d e t e r m i n e  "community-based  which  Health  (CBHC)?  Care In  s t a t e m e n t s made by t h e D i r e c t o r - G e n e r a l Organization Nations  (WHO)  and t h e E x e c u t i v e - D i r e c t o r  International Children's  Primary Health  o f t h e World  Health  of the United  Emergency F u n d  (UNICEF),  Care i s d e f i n e d as;  e s s e n t i a l health care made u n i v e r s a l l y accessible t o i n d i v i d u a l s and f a m i l i e s i n t h e community by means a c c e p t a b l e t o them, through their f u l l p a r t i c i p a t i o n and a t a c o s t that the community a n d c o u n t r y c a n a f f o r d . I t forms an i n t e g r a l p a r t both o f the c o u n t r y ' s h e a l t h system of w h i c h i t i s t h e n u c l e u s and o f t h e o v e r a l l s o c i a l and economic development o f t h e community. 4  Furthermore, Primary  Health  Care i s considered  t o be:  . . . the f i r s t l e v e l o f contact of i n d i v i d u a l s , the f a m i l y a n d t h e 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 possible t o where people live and work a n d constitutes t h e f i r s t element of a continuing health care process. 5  While i n t h e c o n t e x t level with  of c o n t a c t a  person  i n Primary  who  services of a general  participants Health  of  Care —  government ten-point regarding  Health  U.S.S.R.,  in  the I n t e r n a t i o n a l  Declaration  6  programmes i s  prevention  access  "first  and  health  i t may  imply  to the c l i n i c a l  practioner.  134  and n o n - g o v e r n m e n t  programmes.  (PHC)  be s t a t e d t h a t  i n t h e West)  representing  the  countries this  Care  disease  i t should  (as i t t e n d s t o c o n n o t e  Alma-Ata,  developing  provides  promotion s e r v i c e s ,  At  of  They a l s o  agreed i n  on  the  Primary  a s w e l l a s numerous  organizations  of  1978,  Conference  nations  a n d made 22  implementation  September  specific Primary principle  —  adopted  a  recommendations Health to  Care  coordinate  7 their  efforts  care  coverage  subsequent  achieve  through  world-wide comprehensive  Primary  m e e t i n g s between  development methods  to  and  agencies,  encourages c o l l a b o r a t i o n  Care  (PHC).  In  government, n o n - g o v e r n m e n t ,  they  construct  Health  health  are  models  continuing for  to  and  formulate  implementation  and i n t e g r a t i o n o f  that  services.  7  The  mandate f o r t h i s i n t e r n a t i o n a l t a s k i s : . . . t h e a t t a i n m e n t by a l l c i t i z e n s o f t h e world by t h e y e a r 2 0 0 0 o f a l e v e l of health that w i l l p e r m i t them to lead a socially and e c o n o m i c a l l y productive l i f e . . . 8  It  reiterates the  International addition  definition  Health  of  Conference  of a c r i t i c a l time  'health' i n 1946,  adopted but  by  with  the the  scale:  H e a l t h i s a s t a t e o f complete p h y s i c a l , m e n t a l and s o c i a l well-being and n o t merely t h e absence o f disease or i n f i r m i t y . 9  With Health to  t h e Alma-Ata  C a r e o r CBHC, how i s t h i s f o r m  be i m p l e m e n t e d ?  Organization such to  agreement as  (WHO),  According  a  mandate f o r  Primary  of h e a l t h care  service  t o r e p o r t s by t h e W o r l d  CBHC programmes a r e  a way t h a t c o m m u n i t i e s display  self-reliance  initiation,  construction,  Health  t o be i n i t i a t e d i n  can be a f f o r d e d t h e o p p o r t u n i t y and and  self-motivation control  of  in  their  programme: . . . t h e p e o p l e have t h e r i g h t and d u t y t o participate individually and c o l l e c t i v e l y i n the p l a n n i n g and i m p l e m e n t a t i o n o f 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 a n d i n d i v i d u a l s e l f - r e l i a n c e a n d participation i n the planning, organization, operation and c o n t r o l o f primary health care.  the CBHC  3 making t h e f u l l e s t u s e o f l o c a l , national, and other available resources, and t o t h i s end develops through a p p r o p r i a t e education t h e a b i l i t y o f t h e c o m m u n i t i e s t o p a r t i c i p a t e . ... . While these is  statements  an i s o l a t e d ,  actuality of  seem t o s u g g e s t  principally  t h i s i s never  health care  community-based  the case.  coverage,  t h a t a CBHC programme experience,  F o r au a d e q u a t e p r o v i s i o n  i t i s  necessary  for  community  members t o s e e k o u t and depend on t h e p r o f e s s i o n a l , 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 understanding  and e x p e r i e n c e .  of  illness  critical  cholera, Worker the  own p a r o c h i a l s p h e r e o f  F o r example, i n t h e t r e a t m e n t (eg.  malaria,  to the nearest  the necessary  obtained. care  medical  obstructed  etc.),  pregnancies,  t h e Community  Health  (CHW) would be r e q u i r e d t o e s c o r t t h e p a t i e n t o u t s i d e  village  that  is  cerebral  cases  in  clinical  This readily  (with n u r s e s ,  hospital, care  available  and  attention could  infrastructure  d o c t o r s , drugs,  an e s s e n t i a l r e q u i r e m e n t  o f t e n m i l e s away,  so be  of c l i n i c a l  and l a b o r a t o r y s e r v i c e s )  f o r an e f f e c t i v e  CBHC  approach:  Primary H e a l t h Care . . . s h o u l d be s u s t a i n e d by integrated, f u n c t i o n a l and m u t u a l l y supportive referral systems, leading t o the p r o g r e s s i v e improvement o f c o m p r e h e n s i v e 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 t h o s e most i n n e e d . . Primary Health Care i s e s s e n t i a l h e a l t h c a r e b a s e d 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 a n d s o c i a l l y acceptable methods. 1 1  The  d e v e l o p m e n t o f t h e CBHC programmes e n t a i l s  e f f o r t s o f any one community of  health  Instead,  promotion i t  and  t o devise disease  involves village  more t h a n t h e  an a p p r o p r i a t e  prevention  a n d community  system  activities. organizations  9 merging with  more c o m p l e x o r g a n i z a t i o n s  p r o f e s s i o n a l and dialectical authority, The  political  construction  demands.  encompassing  The  involving  added  net effect  differing  i sa  spheres  of  power, i n t e n t i o n s , and e x p e r i e n c e .  Alma-Ata D e c l a r a t i o n  does  not adequately  address the  e n s u i n g p r o b l e m s when i t s t a t e s : Primary Health Care r e f l e c t s and e v o l 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 t h e c o u n t r y and i t s communities and i s b a s e d on t h e a p p l i c a t i o n o f t h e r e l e v a n t results of social, 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 w h i l e  alluding to the  economic, converge  political, in  the  understandably  and  avoids  t o persuade  significance objective of legitimates manifestation is and  "health  Organization and m o t i v a t e  for  i t s call of health  1 3  CBHC  cultural,  forces  that  programmes,  underlying  i t  relations  a l l by  with care  (WHO)  i spolitical in  member  states  To a c c o m p l i s h t h e year  reference solidarity,"  The  to  this  the noble  2000," t h e  to:  "the  the fact  WHO  unique  that  CBHC  o f the o v e r a l l development o f s o c i e t y , "  t h a t i t ought t o justice."  social,  breakdown i n CBHC programmes.  o f t h e CBHC s t r a t e g y .  "an i n t e g r a l p a r t  social  of  i d e n t i f y i n g the  o f t h e World H e a l t h  nature:  of  epistemological  construction  which causes t h e f r e q u e n t task  complexity  be  accomplished  "in  the s p i r i t  of  10, 1.2.2  Problems I d e n t i f i e d i n the Implementation Haaaatiejit o f CBHC Programmes  In  its  health  relatively  care  movement,  numerous p r o b l e m s particularly  doubtful" Health  depth and  1 4  in  programme. initiated  the  agency,  Coordination Centrale) for  of  pour  with  after a  Cameroon  Pittsburgh  from  contre USAID  I n t e r n a t i o n a l Development),  h e a l t h committees" i n t i t i a t e d remained a c t i v e a f t e r the  by  Project  only  years  in a  CBHC  (Organisation  few  "itinerant  en  by de  Afrigue  States of  of to  implemented  United a  CBHC  momentum  l e s Endemies (the  the  organization  example,  OCEAC  remain  programme i s  the  was  often  to  couple of  that  "the  Community  of  or  leaving For  that  the  when t h e  institution,  CBHC  are  unable  goals  and  the  involvement  withdraws,  l a Lutte  funds  of  for instance,  occurs  which  experienced  implementation,  and  members t h e m s e l v e s .  University  have  themselves are  community,  international  community members and  programme i n s o u t h - c e n t r a l the  the  community  frequently  support  an  management  objectives  f r o m an  enthusiastic  with  recorded^  (CHWs)  This  o u t s i d e the  community  of  t h a t the  Workers  interested  been  as  programmes  continuing  I t has  and  history  CBHC  associated  the  programmes. scope  short  and  Agency  the  "village  health  workers"  withdrew i t s  support:  By t h e most g e n e r o u s e s t i m a t e o n l y a t h i r d (15/43) of the committees r e m a i n . Of t h e s e , only three can be s a i d t o be active, the remaining twelve being i n v a r y i n g d e g r e e s of i n a c t i v i t y . 1 5  11 In  another  College  case  —  that  "peripheral health  members were n e v e r  College  withdrew  In  instance,  the  Ethiopian  workers"  consulted  CBHC programme i n t h e i r  this  of  Gondar  project —  Health  community  about t h e i m p l e m e n t a t i o n  area.  Not s u r p r i s i n g l y ,  i t s support,  t h e CBHC  of a  when t h e  project collapsed.  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 private individuals who offer indiscriminate injections t o anyone who c a n p a y f o r them a n d f o r c e d t o 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 t h e m s e l v e s entered the business. 1 6  These are j u s t threatened these  two c a s e s  when i n i t i a t e d  instances,  encounter  between  there the  p r o f e s s i o n a l support community in  and implemented  is  no d i a l o g u e ,  organization that  which i s e x p e c t e d t o  care  appropriate  CBHC programmes a r e unilaterally.  In  communication,  or  should  a c t as  a  s t r u c t u r e i n t h e CBHC programme a n d t h e  the amelioration  health  o f many where  planners  of i t s in  be s e l f - r e l i a n t  own "unmet the  felt  business  and i n v o l v e d needs."  of  CBHC programmes, t h e p r o b l e m s t i l l  For  implementing remains:  How i s i t possible t o implement mutually supportive systems of health care between t h e clinical i n f r a s t r u c t u r e and t h e " 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 o f t h e Community W o r k e r s (CHWs)  Dr.  D.  B a n e r j i , who i s w e l l - v e r s e d  this  problem,  speaks  CBHC  programmes:  o f t h e need f o r  Health  i n the complexity  of  "democratisation" of  12 D e m o c r a t i s a t i o n o f a community and i n v o l v e m e n t o f 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 a p p r o a c h i n which a community i s made t o get i n v o l v e d through a dictate from above thus becomes the very a n t i t h e s i s o f what i s i m p l i e d i n t h e p h i l o s o p h y o f primary h e a l t h c a r e , 1 7  While  "democratisation »  infreguently  happens  administrators perspective Hhile  in  embark on  may  be  implementation.  Those  ambiguity persons  between"  these  what  services.  i s proposed  an area  by  n e e d s " by  of opposition,  the  process  that a r e compelled forces  and  t h e i r own  i n health care  in  i t  Planners  i n terms o f " f e l t  there i s generally and  the ideal,  ' m i s s i o n s ' o f CBHC w i t h  o v e r l a p between  contradiction,  and  i s  reality. ,  a n d what i s e x p e c t e d  community,  "betwixt  CBHC  o f what i s " e s s e n t i a l "  there  initiators the  in  ,  of  t o work  of  traditional  and  imposed, p r o f e s s i o n a l a u t h o r i t y , e x p e r i e n c e  t h e dilemma  most  acutely: . . on t h e one h a n d , CHWs b e l o n g t o a n d a r e r e s p o n s i b l e t o t h e community t h e y s e r v e . On t h e o t h e r h a n d , t h e l o c a l c o m m u n i t i e s c a n n o t by themselves p r o p e r l y g u i d e a n d t r a i n CHWs i n preparation f o r their technical tasks, as well as p r o v i d e them w i t h 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 dual allegiance — t o s e r v e t h e community and t h e health s e r v i c e s . . . l  Community  Health  experiences communities,  B  Workers  (CHWs)  o f doubt and a m b i g u i t y . they  either  seize the  own p e r s o n a l f o r t u n e s t h r o u g h a  CBHC p r o j e c t ,  or  true t o  often  reflect  these  A s l e a d e r s i n t h e i r own chance t o advance  their  the opportunities afforded i n the experience  of l i f e  in  13 community,  transform  altruistically  these  on b e h a l f  benefits  unselfishly  o f t h e "community g o o d . "  Bryant c o n c u r s with t h i s  a s s e s s m e n t o f t h e CHWs  and  J o h n H.  dilemma:  Whereas i n c o m e , p r e s t i g e , a n d p e r h a p s a d e s i r e f o r e a s i e r j o b s seemed i m p o r t a n t a s m o t i v a t i n g f a c t o r s i n one c o u n t r y , 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 t h e community seemed t o b e t h e f a c t o r s a t work i n another. 1 9  To  accomplish  charisma,  latter  may  b u t more i m p o r t a n t l y ,  integrity  to  experiencing them.  the  face  them,  seek t o  transcend many.  a CBHC programme  predominantly  "educative"  dissemination  of family  an  element  health  head  on,  and i n  and h o p e f u l l y  may make p r o v i s i o n care  planning,  programme  disease  the  prevention,  and  villages  drugs,  and  the  care  (see F i g u r e 2 ) .  doctor,"  b e n e f i t s o f Western, c l i n i c a l On  t h e other  made t o  hand,  feel  the opposition  may e x p e r i e n c e  resistance  having previously ministries  in  educational  involve  they  may  health  services,  experience o f to  been  cognitive  Worker  o f these  may  agriculture, feel  dissonance —  be d u p e d .  badly and  development  "modern"  ;  who i s  realities,  The v i l l a g e r s ,  promised " a s s i s t a n c e " care,  expecting  (CHW)  impinging  i n a n o t h e r way.  themselves i n a possibly  may be  additional  t h e Community H e a l t h  for a  (i.e.,  the  "local  resolve  While t h e o r g a n i z a t i o n  h e a l t h promotion knowledge), a  of  t h e f o r t i t u d e , s t r e n g t h , and  the contradictions  F o r t h e problems a r e  which i n i t i a t e s  reguire  by  government water,  treated  —  therefore  programme  Alternatively,  they  or an  refuse  i n which 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 t e m p o r a r y 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.  15 Maternal C h i l d H e a l t h  (MCH)  Clinic  suspicious  f o r other  ensconced  in  culture"  a  that  2 0  reasons;  they  traditionally-based  i t i sd i f f i c u l t  to  t h e new t e c h n i q u e s and p r i n c i p l e s  pay f o r  their CHW  an i n j e c t i o n  when  cure,  he/she v i s i t s but  s i c k n e s s from can  rectify  recommendation fluid And  happening  for  and  treat  t o prepare  a r ethese  the  do f o r t h e  their  home  and o f f e r s  on  how t o  prevent  o r even s u g g e s t s themselves  t h e CHWs  and v o m i t i n g  CHWs a c c o u n t a b l e  o f community  who a r e  expected  These members,  to  (e.g.,  2  motivational s k i l l s  programme  i n Chapters  they the  i n children)? t o an  3  of  and  2 2  "external" principally  b u t more these  immediately,, situations.  2 3  who have t h e o r g a n i z a t i o n a l  to sustain  (see the e x p e r i e n c e  programmes  that  dilemmas a r e n o t o n l y  work i n  They a r e t h e i n f o r m a l l e a d e r s * and  that  no  i n t h e home t h e o r a l r e h y d r a t i o n  t o t h e community?  experience  there  might be i n a p o s i t i o n  government o r n o n - g o v e r n m e n t a g e n c y , o r a r e t h e y responsible  Then  2 1  what s h o u l d t h e y  i t  cases of d i a r r h o e a  lastly,  health  addresses  them  again,  heavily  that tangibly  them i n  simply a d v i s e s  so  "popular  with t h e o l d .  o r drug  experience o f being s i c k ,  be  incorporate effectively  a r e t h e p r o b l e m s o f money; w h i l e t h e y to  may  interest  t h e Nangina  4)  i nthe  CBHC  and S a r a d i d i  or contribute  to  i t s  an  medical  disorganization. In  this  thesis,  I  anthropology  that  n o t been  examine  process  the  has  research  through  area  sufficiently which  CBHC  in  studied.  I  programmes  are  17 socially relate  negotiated this  work  understandings reality doing  —  and a c c o m p l i s h e d to  I  respond  situationally-derived  i.e.,  o f t h e community  i n t h e community,  the  c u l t u r e and  i n which  t o George  and  values  and  epistemological  CBHC t a k e s  place.  F o s t e r ' s recommendation  I n so. when he  says: In Primary H e a l t h Care (PHC) p r o g r a m s greater a t t e n t i o n n e e d s t o be p a i d t o how a community i s m o b i l i z e d a n d i t s f o r c e s b r o u g h t t o b e a r on h e a l t h problems. T h i s means g r e a t e r f o r m a l a t t e n t i o n t o the form and q u a l i t y of f o r m a l and informal l e a d e r s h i p found i n c o m m u n i t i e s where work i sto 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 t h e question o f : . .... how t o p r e s e r v e l o c a l i n i t i a t i v e , i . e . , t h e d e l i c a t e b a l a n c e t o b e a c h i e v e d between t e c h n i c a l a s s i s t a n c e and s u p p o r t o f l o c a l l y g e n e r a t e d e f f o r t  In  t h i s borderland  Community  Health  dissonance  of  these  domains  two  between h e a l t h Workers  attitudes,  (CHWs) values,  (discussed  spite  of the d i f f i c u l t i e s  wider  v a r i o u s CBHC  programmes,  infrastructures  services  of  13)^  reflect  to  epistemologies and t h e i r  but  are i n  study.  a  o f care  their position. t h a t determine  relations or  the  view between  unique p o s s i b i l i t i e s  government  i s the project of this  only  and world  intrinsic  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 these  not  on page  p o s i t i o n t o image a n d c o n s t r u c t in  s e r v i c e and community, t h e  t o the  non-government  18 1.3  IDEOLOGICAL BACKGROUND TO THE INTERVENTION OF CBHC AS A HEALTH CARE DEVELOPMENT STRATEGY T h e r e a r e many e l e m e n t s , r e c o m m e n d a t i o n s ,  of the  CBHC programme  strategies i n emphasis  on  that  the R e p u b l i c development  village-based  movement  efforts,  emerge  and  are  on community-based community  infrastructure  modern).,  that  and  development  community  o f t h e Harambee  the problems t h a t to  f o r example,  controls  on t h e  professional in  reconcile  impinging  the  of  government  support;  and  interface  of  the  problems of s u s t a i n i n g  of  impact  community  CBHC  in  the  members i s  and CBHC programmes.  of  cum  present  a Tq  day  programmes i n Kenya, i t i s n e c e s s a r y t o c o n s i d e r  t h e emergence harambee  areas,  economic systems ( t r a d i t i o n a l  and p a r t i c i p a t i o n  the  the  the f r u s t r a t i o n  2 7  dependence  occur  constructed  understand  of  and powers:  s h a r e d e x p e r i e n c e o f b o t h harambee fully  rural  inability  elites;  their  Because o f t h i s ,  involvement  the  too,  and b u r e a u c r a t i c  for financial  difficulties  differentially  on  political  leaders i n  the  characteristic  authorities  the system o f government  developmental  F o r example,  self-reliance  But here  predicated  principles  i m p l e m e n t a t i o n , and management o f  below).  differentially-based  the  o f Kenya.  programmes i s a l s o (see 3.1  existing  programmes i n  members i n t h e i n i t i a t i o n , self-help  overlap  and  of the  movement.  CBHC s t r a t e g y  in  the context  of the  19 1.3.1  The  "Harambee" Movement  When Kenya 1963,  attained  Jomo K e n y a t t a  "harambee."2 together," cry  In  a  "aaaaa  -  is  the  "freedom;" having  and  Today,  slogan  the  the  for  of  Daniel  of  arap  imperative man,"  the  of  many  returning support, notions the  harambee the  the  following  respects, to and  that  slogan  the  are  Written  the  in  the  government  reiterates  the  Mzee  on  of  this  (the  "old  footsteps." harambee  practised  is a  systems  plea of  for  work,  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  still  r u r a l areas of  for  nation.  initiative  Nyayo  "in his  and  i t symbolizes  current  famous by  call  traditionally care.  used.  of  the  African  i s widely  community  meaning  redress  equitable  With t h e  harambee made by  between  motto,  Before  3 0  Uhuru to  "pull  work gang  push."  was  1,  nation,  means  the  was  task  June  new  j u s t and  nation's and  -  force  existed  more  country.  Moi,  Kenyatta)  In  a  self-reliance  development  in  build  c o u n t r y ' s s e a l as  need  that  the  from  ready  t h a t , the  to  on  literally  to d e r i v e  mobilizing  situation  cry  harambee  meaning  attained  European,  Self-Government  rallying  purported  mbee!  Independence,  unequitable  gave t h e  Kiswahili,  and  2 9  Internal  a p r i n c i p l e of  community  obligation  Kenya:  . , . . t h e Luo c a l l i t K o n y i r Kende, the Luhya obwasio, t h e Kamba Mwethia, the K i k u y u Nqwatio, and t h e M a s a i Ematonyok . . . 3 1  and  i t  involves  planting,  and  the  collective  work i n v o l v e d  in clearing,  weeding g a r d e n s , b u i l d i n g houses or r o a d s ,  and  20 now,  the  schools,  activity community  of  constructing  halls,  i n s t i t u t e s of t e c h n o l o g y . o b l i g a t i o n of working kind  of " t a x a t i o n "  required  unpaid l a b o u r . kind  of l a b o u r  3 3  There  designed  members).  of r o a d s  to  and  and  the  of "pushing  community  is  and  not  recently community  turned  into  u n e m p l o y e d men  24-60 d a y s  distinction  the purposes railroads  that of  ameliorate  most  days,  all  (harambee)  of on  between  felt-needs  pulling"  always  this  of  the  of  a harambee p r o j e c t  the  in  developing behalf  a  were  a year  Nevertheless, there are s i m i l a r i t i e s  relationship rural  i s a clear served  and  p a r t y " was  f o r approximately  c o l o n i a l government) is  In c o l o n i a l  3 2  i n t h e "work  (which  infrastructure  dispensaries,  i n human l a b o u r ,  t o work  self-help  the  (which  community, i n that  the  between g o v e r n m e n t  and  complementary i n  harambee  projects. Initially,  the  initiatives  of r u r a l ,  professional  services.  that  peasant  promised  F o r example,  school, provide  they  organized would  a teacher.  dispensary  and  expect  community  nurse.  response dramatic,  to the that  call  the  the  government However,  t h e g o v e r n m e n t was  felt great the  of Education  to  might b u i l d  to provide  was  with  or  build  they  the  f o r harambee  and  work t o  Ministry  the  community  location,  alternatively,  match  with funds  if a  t h e money and  expect  to  communities  they needed a s c h o o l i n t h e i r  resourcefulness  and  government  the  a  drugs  post-independence so  immediate  ill-prepared  and  t o match the.  21 initiatives  of the  hundreds of  "develop themselves."  As  c o m m u n i t i e s who  a result,  schools,  dispensaries,  and  physically  constructed  are not  tangible  but  reminders of  the  diminishing  faith  prepared  meet t h e i r  to  wananchi about To  90%  (in of  in  the  total  the  are  this notion  of  through c e n t r a l  the  coordinate  President.  Secretary  plans  According  in this  is  o n e s who  not  as and  always  citizens  suffer,  the  or  making  government  "participative  applications  the development  been  frustration,  ordinary  tendency,  channeled  with  the  have  They r e m a i n  that  The  of  c o n t r i b u t i o n s i n harambee p r o j e c t s .  that  to  work,  hundreds  are  i n use.  hard  to  that  3  needs.  Requiring  attempting  clinics *  government  Kiswahili)  counteract  introduced  a  there  attempted  for  haEaibee  ministries, grassroots and  the  t o G.K.  has  centralism." projects  be  government  is  development  s t r a t e g i e s of  3 5  projects  the  Kariithi,  Office  of  a Permanent  Office:  The t e r m i s meant t o indicate 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 , nevertheless, a very high degree of i n d i v i d u a l and g r o u p p a r t i c i p a t i o n by the people themselves. This term i s not very f a r removed from Harambee, w h i c h i n i t s d e e p e s t r e f e r e n c e s , i s more than just putting up a health centre. Harambee, o r 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 total s y s t e m which u n d e r l i e s o u r p o l i t i c a l , e c o n o m i c and social procedures. 3 6  In  the  face  government has  of growing d i s c o n t e n t attempted  of "development" by  rural-based,  to  Iharambee,  i n the  rural  areas,  regain i t s bureaucratic self-help)  peasant communities.  activities As  a measure  the  control  initiated designed  22 to l i m i t is  the i n c r e a s i n g  an a d m i n s t r a t i v e l y  presumes  to  e x p e n d i t u r e of scarce  rational,  curtail  the  resources,  restorative strategy:  repetition  of  already  " e s s e n t i a l s e r v i c e " programmes i n t h e s e a r e a s care,  water,  agriculture,  government's p o i n t rising  of view,  frustration  involved rationale  in  of  will  the  average  hara.mb.ee p r o j e c t s .  of t h e government  this  and  purportedly  i t  planned  (egs.,  and e d u c a t i o n ) ,  i t  health, f r o m the_  d i m i n i s h the  citizen  Cwanansfri).  Holmguist summarizes  the  way:  Self-help was thought to be i n e f f i c i e n t and wasteful, l e a d i n g t o poor grades o f c o n s t r u c t i o n ; community c o m p e t i t i o n often l e d to a d u p l i c a t i o n o f s e r v i c e s and c h a o s i n the c o n s t r u c t i o n process. Self-help, i t was argued, also encouraged political attempts to influence bureaucratic allocations, which only disrupted budgeting p r o c e s s e s and o p e r a t i n g p r o c e d u r e s . , S e l f - h e l p was a l s o , s a i d t o be f r u s t r a t i n g t h e p e a s a n t r y when outside assistance failed t o materialize o r when the government r e f u s e d t o t a k e o v e r 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 o f d i s i l l u s i o n m e n t w i t h t h e r e g i m e when i t was s e e n t h a t l o c a l e f f o r t met w i t h l i t t l e o r no matching response from government and that dispensaries, f o r example, remained without medicine o r p e r s o n n e l . 3 7  Nonetheless, administrative development intrigue. represent  i n spite  of  situation  this  current  ('participative  p r o j e c t s c o n t i n u e t o be f r a u g h t Leaders harambee  who  are  projects  elected  are expacted  Holmguist  still  an a p p a r e n t  and  calls  t h e government:  "pre-emptive  political  with  t e n s i o n and  encouraged  t o persuade This  strategy  development"  f o r c e between  and  centralism"),  and  government t o move i n c e r t a i n d i r e c t i o n s . which  political  the  3 8  rural  —  to the — is  elites  23 The p o i n t i s not to c h o o s e s o m e t h i n g which you know i s already in the government's p l 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 t o go in a direction 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 C u r r e n t P o l i t i c a l , S o c i a l , and E c o n o m i c S i t u a t i o n i n The R e p u b l i c o f K e n y a : P r o b l e m s "Development" ~" "~ -  The basis  strategy  " p r e - e m p t i v e d e v e l o p m e n t " o p e r a t e s on  of i d e a l i s t i c ,  First  of  a l l ,  flexible  enough  development  Kenya —  as  that  to  to  respond  the  of  of the  Ministry  critically  development As  flienen  Kenya's  administration:  Countries  suggests i n  assistance.  —  Republic  i s geared  [see  of  to a and  Chapter  2  I t functions  control rather  another  for  implementation,  programmes  evaluating  is  requests  i n the  of Health).  programme o v e r  need.  administration  machinery  planning,  government  f o r c e f o r d o m i n a t i o n and of  World  for  the  self-help)  bureaucratic  the  i l l - f o u n d e d assumptions.  individual  harambee,  structure  administration  capable  culturally  i n most T h i r d  "top-down"  case  and  i t presumes  [or  Unfortunately,  the  of  of -  for as  a  t h a n a body w h i c h i s the  in  merits  of  terms of  his r e i t e r a t i o n  of  one  relative critics  of  . . . i t is recruited and organized for maintenance of order and control, not for innovation 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 highly centralized and bureaucratic nature of the C i v i l S e r v i c e ., . . militates against i t s being a change-oriented i n s t i t u t i o n . * 0  Secondly, representation  i t of  assumes tribal  and  that ethnic  there  is  groups i n  democratic the  central  24 government  ministries.  currently tribal  (sic)  and  increasingly political  top  state  independent,"  resources  visibility  in  minority  that  social,  and  transition  4 2  by  very  an  government powerful  "oligarchy that  upper-level  compete  with  will bolster their  who  positions.  Kikuyu cabinet  has  become  managers  are  other  for  status  and  own  This  immediately  gained c o n t r o l of  is  of  each  home c o n s t i t u e n c i e s .  political  this  two  these  individuals  Independence r a p i d l y  the  bureaucrats  who  their  of  by  represented  4 1  aspirants  financial  reality,  controlled  factions;  ministers  In  is  the  following  s t r a t e g i c economic, Bienen  describes  the_  way:  I n a b s o l u t e and r e l a t i v e numbers more K i k u y u were upwardly mobile as they took over from Asian traders, purchased l a n d from other t r i b e s e i t h e r alone or i n c o n s o r t i u m s and cooperatives, moved i n t o the former white farms, began t o move i n t o foreign 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 t h e o f f i c e r corps. At t h e same t i m e , Kikuyu were b e c o m i n g l a n d l e s s and u n e m p l o y e d i n l a r g e n u m b e r s . 4 3  Whereas f o r m e r l y four-fifths tea,  of  a small  the  agriculturally  c o f f e e , sugar cane,  swiftly  appropriated  elites.  ensconced  which s u r r o u n d s the surprising that  funds  by  of  Europeans c o n t r o l l e d  productive  sisal,  and  wheat),  this  small  land  (i.e.  in  land  was  this  minority  of  Kikuyu  4 4  Permanently  all  minority  i s currently  in this  capital city a  highly  of N a i r o b i ,  disproportionate being  productive  diverted  i t  amount o f  to t h i s  area  land  i s not  at  government known  as  25 Kikuyuland that  is  [i.e.  Central Province).  generally  given  visible,  urban-based  example,  i n the  i s usually facilities  health  sector  s h i l l i n g s have been s p e n t on in  Nairobi.  institution  Even has  d y s f u n c t i o n a l and t h e wananchi  given  badly  i s clear:  allocated  to  and  institutions.  alone  m i l l i o n s of  this poor  designed  massive marks  message t o  means t h e D e v e l o p m e n t  the promotion  water,  education,  Given the r e a l i t y economic  situation*  (whether  they  classes)  are  bewildered. with  further still  be  of  this i t  5  —  or  t h e Luo  feel  that  economic r e s o u r c e s ; an e l i t e  well-heeled  Uhuru  during  an a p p a r e n t i n e g u a l i t y  control,  —  (Self-Help/Development)  t h a n t h e s t a t u s guo  rather minority  individuals  income-generating  in  impoverished  historically  and  a t odds  (Independence/Freedom), have b r o u g h t  colonial rule.  minority  of p o l i t i c a l l y (mainly  and  groups  disillusioned  the o v e r a l l  than a  social  peripheral  economically  like  care,  areas.  why  increasingly  amenities,  health  l e s s than e g u i t a b l e  i s clear  tribal  Groups  and  of  of comprehensive  involving  w e l l as i n r u r a l  becoming  the K i k u y u *  and Harambee  programmes  agriculture,  programmes i n u r b a n a s  care  the  and s t a t u s e s )  "development"  Hospital  clinically  ( i n modern s e r v i c e s ,  community  Kenyan  a  Western images o f w e l l - b e i n g than  For  health  as  facility,  "development  rather  publicly  the Kenyatta N a t i o n a l  though  been  F u r t h e r m o r e , t h e money  Kikuyu)  them  no  There i s  distribution  of  of Europeans i n and  economically dominate  the  26 remaining  tribal  brandished  as  constituted  and e t h n i c the  symbol  movement  functions  instead  attention  away f r o m  groups. for  towards  as  an  While  an  ethical,  the  "good  ideological  this  "Harambee" i s  minority  and  justly  society,"  gloss  which  and t h e  4 6  i t  diverts  resources  i t  controls. Those t r i b a l find are  thwarted m a j o r i t i e s  t h e m s e l v e s on t h e p e r i p h e r y fully  cognizant  elite,  As  tribal  and  racial  poverty  tribal  4 7  disparities  there  tensions  a widening  and t h e  elites,  of these c e n t r e s  has  b e e n an  entrenching  culture  of  only  too  embarrassed  find  themselves l i v i n g  Nairobi). feel fact  to  Students  the i n j u s t i c e that  families. closure  many  And y e t , of the  often leave  communicate t h e i r i n city  slums  their  and o f the  4 8  difficulties. with  hopes  much p o o r e r ,  misfortune at  or  home,  Hathare V a l l e y i n  of Nairobi  as well  s i t u a t i o n i n s p i t e o f the  from  p r o m i n e n t and  protestations  University,  that  [eg.  at the University  them a r e  these  t h e major c i t i e s  of the current  of  economic,  economic r e c e s s i o n o f  intensified  who s u r g e i n t o  dreams o f employment,  and  and urban government a s s i s t a n c e i n  the  and  of  the culture,  an a c c e n t u a t i o n  The w o r l d - w i d e  1980's h a s  regionalism  political,  and s u b s e q u e n t l y ,  between r u r a l  Those p e a s a n t s  o f power,  exacerbation  o f t h e g u l f between  "essential services." early  that  of the actual machinations of the r u l i n g  a result,  parochialism, of  and e c o n o m i c a l l y  and  have o n l y  powerful  l e d to the  a confirmation  of  how  27 oppressive is,* as  and  To l i v e  9  the  today  democracy  fragmented  subsistence  freedoms of evolution  1.3.3  of t r i b a l  the  context  development  economy,  social,  i n wealth,  a  a r e p r e s s i o n of  communication,  ethnic  and  a  critical  tensions.  in  ineffective deliberate  the  and  of  politically-charged  has  emerged  Mutiso,  strategy of  of  the  central  attempt t o get  s u p p l i e s , and  competitive  defensive the  the  opulent  periphery  what i t c a n  and  to squeeze  arrogant  reactionary, aggressive,  winner.  government and  Holmguist claims that " s e l f  game between g o v e r n m e n t  party the  a  in  a  terms  professional assistance.  development t h r o u g h c o o p e r a t i o n ,  stridently  as  self-help  5  organized  a seemingly  areas  harambee a n d / o r  and  movement. <> I t i s a r e a c t i o n a g a i n s t  support,  G.C-M.  defensive  this  rural  bureaucracy  of f i n a n c i a l Citing  of  stringent situation,  reactive social  than  the s e v e r i t y  economic,  disparities  market  and  and  really  increasingly corrupt oligarchy, a  and  expression  economically  out  an  experience  political,  The  situation  Harambee, D e v e l o p m e n t , and Communj.ty-Based H e a l t h C a r e : s i m i l a r P r o b l e m s o f S u p p o r t , M e d i a t i o n , and Involvement  In  and  with  political  i s to  of t h i s  cultural situation.  crippled  one  i n Kenya  w e l l as complexity  and  is  repressive  help  is a  what i t can  center."  5 1  Bather  the  harambee movement  and  cunning;  and  community  i t is a with  only  28 To  s u s t a i n the involvement  members i n  and p a r t i c i p a t i o n  t h e harambee p r o j e c t  requires a  o f community  commitment and  a l l e g i a n c e t o t h e g o a l s and o b j e c t i v e s o f t h e p r o j e c t ; can  only occur  i f there  meanings,  and b e l i e f s .  community  desires to  culture, "focused  Given create a  more  situation"  and  a  value s t a n d a r d s . "  community  d e l i b e r a t e and  leaders  motives, and  to  conscious  purge  who  unifies  the  traditional  members  in  group —  egs.,  excellence  symbols, members  boundaries.  people  there  i s  the  selfish  lion,  strengthening  to  the  -- t h e r e i s a needs,  an  a r o u n d common  interests  a common  symbol It  may  which be  a  that i s r e v i t a l i z e d i n totem animal o r  k i n s h i p , o r neighbourhood  or snake),  modern and  i s increased a  r e s p e c t e d and  personal  movement.  symbol  new  and  o r an a c q u i r e d  Western s t a n d a r d s  [eg., a Mercedes-Benz)!  there and  of  and  movement a s a  "married" 5  an age-set,  a bull,  symbol that r e f l e c t s and  are  world  ground f o r  d u r a t i o n o f t h e p r o j e c t {a  name t h a t d e r i v e s f r o m  t h e haramb.ee  d i a g n o s i s o f community  c l a n o r community  meaning f o r t h e  self-help  development *  t h e movement  Usually  experience,  satisfying  M o b i l i z e d by  5 3  —  and a g a t h e r i n g o f  concerns.  that  "manufacturing  p r o j e c t f o r the d u r a t i o n of i t s  attempt  the fact  Mbithi characterizes the  5 2  v a l u e s and elected  i s a framework o f s h a r e d  this  Motivated  "solidarity" and  5 5  of  by these,  between  tightening  wealth  of  group group  29 As  mentioned,  development) are  —  ;  like  unilaterally  frustration, accomplish between  and  o f CBHC programmes  often The  the  communities  o f government  have r e l i e d  —  projects  periphery have  in  the  is  on t r a d i t i o n a l  I n an i n t e r e s t i n g  Were o f t h e  Department  University  of Nairobi,  she f o u n d t h a t  (the n a t i o n a l  organization  study  always division  increasingly an  obvious  harambee  —  and  o r g a n i z a t i o n s of carried  o f Community  o u t by  Health,  the  even t h e M a e n d e l e o f o r women)  c o n f i d e n c e i n t h e e y e s of r u r a l ,  that  failure,  do n o t  developed  M i r i a m K.  little  ends  programmes — l i k e  more i m p l i c i t l y  s u p p o r t and c a r e .  Wanawake  (self-help  p r o m i s e d , and a s a r e s u l t ,  centre Rural  movement  the s i t u a t i o n  and d e s p a i r .  the  suspicion  harambee  imposed  what t h e y  widened..  the  ya  inspired  p e a s a n t 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 viable at g r a s s r o o t s i n t h i s community. The g r o u p s t h a t d i d e x i s t (through w h i c h women a s s i s t e d one another with t a s k s s u c h a s weeding) were c h u r c h - r e l a t e d and/or n e i g h b o u r h o o d g r o u p s . s 6  Harambee  and  government identify the  Maendeleo  inspired  specific  process of  water, e t c . )  groups  amelioration,  Harambee,  are  perceived  At a c e r t a i n  felt-needs i n rural limit  programmes  level  communities,  ( f o r women,  and  community)  and m o t i v a t i o n  Maendeleo  ya  in  that  community  Wanawake.  and  they  for  i n health,  would members. CBHC  as  but i n  the p o s s i b i l i t y  a n d t h e d i a l o g u e and c o m m u n i c a t i o n  (government  participation  Wanawake  interventions.  comprehensive development in  ya  between inspire For  programmes  30 (whether government between  o r non-government)  (i) government/non-government  community  organizations  development  problems:  and  sustaining  yet,  i t i s through t h i s  effective  1.4  organizations  the  and ( i i )  most  the d i f f i c u l t y  supportive  interface  i n creating  systems of  tension  that  t h e most  of care  have  emerged.  serious  care.  i s i n t h i s context  (though s u p p l e m e n t a r y ) heels  health  o f t h e Harambee  on a " b r o a d promise  t h a t CBHC emerges  as  development  (by  the  latest  programmes.  in  discussion leaders  of the  implications  is  government  the  series  there  and  to  them;  (as i n  of t h i s  the  rural  kind  of  of complete c e n t r a l or very  little  and  the  the nature  and  and  once  the  Harambee p r o j e c t s ) ,  t h a t t h e community for  warily  leaders i n  (i.e.  as  the,  "self-help"  representatives  community"  infrastructure  is  i s generally  programme f o r  no a s s u r a n c e  of  meaning  above  been i m p l e m e n t e d  supplies, financial,  a  Health)  on  emphasis  areas,  i s the experience  government  "target  of  programme h a s there  bodies);  between  Following  in rural  of  wise to.the  t h e programme f r o m  government  effort  Representative  " s e l f - h e l p development:" there  district  as an a l t e r n a t i v e  strategy.,  the Ministry  communities a r e becoming  control of  5 7  and  SITUATION  movement and t h e c u r r e n t  based d e v e l o p m e n t "  o f CBHC  perceived  care  And  innovative  THgORETJCAL CONSIDERATIONS: THE ETHNOGRAPHIC OF CBHC i B O G l A l H E S I S KENYA It  the  this  organizations  generates  that i s ,  mutually  alike,  continuing  can r e l y  on t h e  allocations  professional assistance.  of  31 And  yet,  so-called  in  s p i t e of  to ameliorate f o r them  their  (CBHC)  they  will  that  much w i s e r  respond  consciously  This  —  they  their  constructed  f o r CBHC,  the  Project  Director  for  development  Programme  together  support that  only  power.  true  and  who  would  community  yet desperate F u r t h e r m o r e , by  of s e l f - r e l i a n c e and to  the  o f what  by  definition [except f o r  this  strategy  i n t e r n a t i o n a l health  So t o o t h e  N a n g i n a Community  i n this  clan-based  an o r g a n i z a t i o n  later  have  own i n d i v i d u a l  t h s knowledge  (see c h a p t e r 4 ) ;  hospital,  Project  leaders  as an i n d i r e c t ,  without  mean.  Development  project  and a few o t h e r s )  to  be  e x c l u d e the i n v o l v e m e n t of  has been c o n c e i v e d  organizations  mission,  and  will  upon by t h e c a d r e o f  is  health,  i n t e r e s t s as a  for their  political  that  take,  possibility,  leaders  their  a r e e x e r c i s i n g a form  self-determination  discovered  agreed  they  out p o l i t i c i a n s  platform  c a n be i n t e r p r e t e d  doing t h i s ,  Health  the  p r i n c i p l e to  attempt t o e x e r c i s e  care  example,  political  aspirants  —  their  Sural Health  and d e l i b e r a t e l y k e p t  advancement.  leaders  t h e name f o r t h i s  and a d e p t a t p r o t e c t i n g  for  made a v a i l a b l e  I f community-based  that  in  programmes,  needs; i t i s a r i s k  to i t hoping  3) ,  i t a  political  any o p p o r t u n i t y  as  In the S a r a d i d i  chapter  (harambee)  worth t a k i n g .  i s presented  community.  make of  seize  perceived  a risk  care  (see  apparent d i f f i c u l t i e s  " s e l f - h e l p development"  r u r a l communities w i l l  and  these  instance,  communities  f o r caring  have t h e y come t o r e a l i z e  and  the have  mutual  subscribes  32 to  the  from  n o t i o n o f CBHC.  a  CBHC  k i n d o f 'growing  understandings  of  together'  of  —  and t o c a r e  "experimenting"  with  o r g a n i z a t i o n s o f implementing p r o m o t i o n programmes, mutually-supportive  health  developing care for  of  even  i t  a l l by t h e y e a r  terms  of  a  services — perceived services  2000"  according  to  and  drugs  the and  already  training  and  malleable  Prodded  Intent  on  call  f o r "health  Health framework —  i s merely  [from  care i s  clinical  potential  gradually  in  of  appended  implemented hospitals,,  sub-centres,  to  on by a i d o r g a n i z a t i o n s who p r o m i s e  h e a l t h c a r e programmes  e m b a r k i n g on  i nits  static-based health  curative  health  clan  The M i n i s t r y ,  i s .  facilities  centres,  viable,  the  available  therefore,  with  M i n i s t r y o f Health has complied i s  between  system.  readily  programme o f p r o v i d i n g c l i n i c a l  fund  a s t h e most  t h e v e h i c l e o f CBHC)  and t h e  planned  to  and h e a l t h  t h i s conceptual  onto  dispensaries).  prevention  and  epistemic  CBHC,  health  dependent  services. ,  means  d o c t o r s and n u r s e s .  rural  more  c a r e system  [through  adequate  providing  this  After  has responded t o the  biomedical  as  f o r one a n o t h e r .  disease  CBHC  merging of one i n  f u r t h e r i t s network o f  facilities,  to  hand, has been l e s s  what  has e v o l v e d  be a t  CBHC h a s emerged  H e a l t h , on t h e o t h e r  appreciation  be,  other,  communities and t h e h o s p i t a l - b a s e d of  setting a gradual  what i t means to  community, t o be h e a l e d , years  i n this  pilot  a central  CBHC f o c u s ,  -- y e t o n l y  on p a p e r -—  programmes  i n CBHC  that  are  33 planned,  implemented,  and  i n Nairobi  (see chapter  headguarters It  will  {chapters as  be e v i d e n t 2-4) t h a t  a gloss  in  supposedly  managed  2) .  the ethnographic  "community-based  f o r achieving  from  cases  health care"  presented (CBHC)  comprehensive f a m i l y  planning,  disease prevention,  a n d h e a l t h p r o m o t i o n programmes —  be  situationally-derived  related  and  t o these  understandings.  t h r o u g h which (hopefully) necessary  accomplished  t o n o t only  taking root, infrastructure mission, most  Furthermore, i n e x p l i c a t i n g  CBHC programmes  of h e a l t h care  are socially  in  interpret  rural  but the c u l t u r e as  well —  instances,  t h e c u l t u r e and  but  (eg. research)  rather,  cultural embroiled  either  or opposition.  a  in  dialectic  evidenced  CBHC  health  care  by g o v e r n m e n t ,  organizations. systems  in  are  In  never  r e l a t i o n s h i p s of  In short, there i s that  engages  s p h e r e s o f a u t h o r i t y , power, and w e l l - b e i n g . ,  the experience  individuals) impinging  epistemology  which CBHC i s  situations  a fundamental i s s u e i n the mediation is  i t i s  superordination/subordination,  competition/cooperation,  differing  in  of the supporting  two  the process  n e g o t i a t e d and  whether p r o v i d e d  these  beliefs,  communities,  k n o w l e d g e o f t h e community  o r non-government  complementary,  values,  must  of  individuals  of these d i f f e r e n c e s  [and c o l l e c t i v i t i e s  who s t r u g g l e t o work t h e m s e l v e s c l e a r  cultural  constraints  imposes o r i n t e r v e n e s  with  —  that of the  of  o f these  system  which  a model f o r CBHC, and t h a t o f t h e  34 rural-based them i n  community  the  which has  programme.  As  H e a l t h Workers  (CHWs) —  liilaae  Committees  Health  nurse-trainers — impinging these  epistemological worthwhile.  evaluation  the  may  be p r e d i c a t e d on and/or  ethnographic  Community H e a l t h distinct  advancement Saradidi  most  cases,  contribution Nangina  the  Rural Health  his/her t r a d i t i o n a l in  for  CHW  by  them  of  moral are  a CBHC money,  work.  traditional the  three  for  of  Pilot  of p r o f e s s i o n a l  system;  the  CHW  in  i s inspired  nyamrerua —  lastly,  Programme  the  a number  Ministry of Health  the  self  programme,  In  together  the  i s an  with  respected f o r t h e i r and  and  deemed  It  relationships  f o r reasons  c o u n t e r p a r t -—  Health  these  impact  dialectic.  Development P r o j e c t  and  the  worthwhileness  i n the  i n t h e community;  Community  of  health care  honoured  position  of CHW  which c o n t a i n s f o r  gathers  CBHC i s m o t i v a t e d through  system  i n terms of  of b e l i e f  (CHW)  the  and  i n s t a n c e of  presented,  Worker  support  t h e s e CHWs  and  perceptions  processes:  project for  i n the  issues  cases  Community  accountability,  this  of one's e x p e r i e n c e s and  the  different  which  elements of  with o t h e r s ,  represent  represent  themselves  relevances  and  values,  which  W o r t h w h i l e n e s s i s a word  individual a l l  the  Constrained  systems  to s i t u a t e  with  i n t h e i r person  f o r a l l e g i a n c e and  are compelled  mentioned,  to  (VHCs), P r o j e c t D i r e c t o r s , and  systems.  cultural  requirements  was  together  refract  epistemic  s e l e c t e d them  t h e CHW is  the by  and i s * work  and  in th%  encouraged,  35 strengthened, their  and drawn  to their  C h r i s t i a n Community G r o u p s  1.4.1  other  a series of  Kenelm B u r r i d g e  theoretical explores  5 8  in a  and  explain the  generation  The  significance  understanding  and  into  ethnographic  to conceptualize  of s o c i a l ^ c u l t u r a l  h i s theoretical  views  explanation  on  i s evident and  specifically,  (structural  I will  that  each  address  each p e r s p e c t i v e i n t u r n  situation  i n t h e country,  represents  oriented  culture,  emerging  out of  and/or peasant  analysis,  of this  o f CBHC b r i n g s  a  modern  and w h i l e and  social  confluence  and m o r a l r e q u i r e m e n t s ,  s o c i a l organization  are clearly  separate  f o r rural,  t h e agent of 5 9  as  subsistence  I n terms these  More  CBHC e v e n t s  o f complex,  organizations.  together  scientifically  i t i s useful t o think of the  thesis.  systems.  s i n c e CBHC programmes a r e d e s i g n e d  usually  economies,  an  and phenomenological) ,  sometimes d i s p a r a t e c u l t u r a l  more p e r i p h e r a l a r e a s change  to  h i s explanatory  relational  as i t e l u c i d a t e s t h e a n t h r o p o l o g i c a l problem  differing  movements.  contribution  t h e o r e t i c a l elements o f his  individuality,  It  opposing  o f CBHC programmes i s r e p l e t e . . S e p a r a t i n g t h e  methodological framework  Social-  between  s u c c e s s f u l attempt  of  other.  p u b l i c a t i o n s i n anthropology,  the borderland  c u l t u r a l systems  persons i n  (CCGs) and by e a c h  Complex, S u b s i s t e n c e , and P e a s a n t 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 I m p i n g i n g C u l t u r a l R e a l i t i e s i n CBHC ~ ~ ~  In  and  work b y  of values,  c o n f i g u r a t i o n s of in  their  symbolic  36 and,  epistemological  peasant  social  characterize considered  basic  organization,  subsistence  defines  elements  culture:  in  endeavours, of t h i s While  and t h e  specialists  are  certain  service  take  only  later  relations  between  in that  elementary  to share the f r u i t s and f r i e n d s .  6 1  occasions to  capacity  be subsumed of  part  prestige  as diviners,  their function i n this to  whole  i s g r a n t e d on t h e b a s i s  neighbours,  [in their  a c t i v i t i e s and n e c e s s i t i e s such,  combination out a  d e f e r r e d t o on c r i t i c a l  m a g i c i a n s , and h e a l e r s ) , temporary,  a  flesh  s t a t u s and  the a b i l i t y  relatives,  that  organizations are  and s u c c e s s i n a c c o m p l i s h i n g t h e s e  and i n a d d i t i o n ,  for  relations  community  i n t h e community  work w i t h  provide a  the  except  6 0  relations that  a l l persons  sex,  complex  exclusive.  subsistence a c t i v i t i e s ,  of age,  social  S u b s i s t e n c e e c o n o m i e s as and  accrues t o persons  Indeed,  the  and  t o be m u t u a l l y  Burridge of  construction.  by t h e  capacity i s day t o  day  t h e s u b s i s t e n c e economy.  As  persons a r e c o n t i n u o u s and o n g o i n g :  A g i v e s t o B, B r e t u r n s t o A, A a g a i n 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 b o t h p a r t i e s e x p r e s s t h e m s e l v e s s a t i s f i e d , o r when one becomes t h e p e r m a n e n t d e b t o r of the o t h e r and so the l a t t e r * s retainer. Basically and i n principle the moral determinant of S u b s i s t e n c e economy i s t h e e q u i v a l e n c e o f g i v i n g and r e c e i v i n g [ g i v i n g =0= r e c e i v i n g ) . 6  While cyclical  2  i n S u b s i s t e n c e economies t h e r e repetition  i s a c o n t i n u o u s and  o f t h e s e a c t i v i t i e s and  e a c h g e n e r a t i o n . Complex e c o n o m i e s a r e s t o p p e d the i n t r o d u c t i o n  of money.  6 3  relations short  with  through  Honey p r o m o t e s t h e c o n s e r v a t i o n  37, and  accumulation  temporal  and  subsistence  of  wealth  vulnerable  economies  and  resources  state of and  —  •things  unlike of  encourages t h e  value  the in  1  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  t h a t o f t h e l a r g e r community  of  persons:  Health, i n money, c a n a c c u m u l a t e and command labor, services, a n d goods not a v a i l a b l e i n a Subsistence economy. Whereas in a Subsistence economy exchanges are continuing [A« ^ B) , prescriptive, and within 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 traditional moralities, transactions w i t h money may cut the r e l a t i o n s h i p w i t h a s i n g l e do u t d e s [ A ^ = t B ) , make free markets possible, open relationships to c h o i c e and p r e f e r e n c e , c o n v e r t t h e m o r a l i t i e s i n t o allowable o p t i o n s . 6 4  With  money, t h e r e f o r e , a p e r s o n  i s r e l e a s e d from  p a t t e r n s o f 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 . is  still  there  alternatively, a person  to  submit  feeling  can develop  to  traditional  traditional  The o p p o r t u n i t y authorities,  or  c o n f i d e n t t h a t one c a n make i t a l o n e ,  r e l a t i o n s h i p s t h a t a r e s e l f - s e r v i n g and  self-enhancing. f o r Community H e a l t h money —  i n t h e form  -- i s c o n s i d e r e d  Workers  i n CBHC  programmes,.  of a s a l a r y or remuneration  forservice  t h e key t o t h e i r  professionals  and  individuals.^  On o c c a s i o n ,  compelled)  there  (husband o r r e l a t i v e ) money.  In t h i s  traditional  or  advancement a s h e a l t h  therefore socially  t o become  nevertheless,  (CHWs)  successful,  however, t h e CHWs c h o o s e  volunteers generally  modern p r e s s u r e s  t h e CBHC  appears  the s o c i a l  situation,  in  from  pressure  they or,  care  modern [or are  programme;  some  quarter  t o work o n l y f o r  can e i t h e r s e i z e d by  submit some  to  other  38 awareness o r s e t o f r a t i o n a l i z a t i o n s , situations of relevance.  As B u r r i d g e  create  more  compelling  suggests:  . . the c r i t i c a l situation i s where t h e t e n s i o n s between g i v i n g , =C= r e c e i v i n g and giving receiving occur within the same aggregation. For i n this situation, 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 identities to be encountered within a p p r o x i m a t e l y t h e 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 m o r a l 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  This  dilemma o f  t e n s i o n with the is  non-equivalent  fundamental  worthwhileness  the  other  position  t o hear —  F o r t h e CHWs i n t h i s  And y e t ,  either  through  —  i s  There  6 6  study,  one s e t o f  forlife  f o ralternative  itself  in  p e r c e i v i n g CBHC a s an  possibilities  opportunity  avenues of change p r e s e n t s  communities.  adherence t o  or another.  that creates  community,  on  (reciprocal)  (non-reciprocal)  i n Peasant  t o be made.  hinges  moral p r i n c i p l e s  economies  economies  experience  always a choice  event  equivalent  d i r e c t i o n s and  f o r those  revelations,  i n the  who a r e i n a  conversions,  and  dreams.  1.4.2 The  R e l a t i o n s h i p s , S t r u c t u r e s , and E v e n t s i n Ethnographic Explanation person  ambiguities  who e x p e r i e n c e s inherent  between c o n f l i c t i n g hand,  there  in  t h e o p p o s i t i o n s , t e n s i o n s , and  the  peasant  systems o f moral r e l e v a n c e s .  a r e t h e o b l i g a t i o n s and  follow relations  of k i n s h i p ;  payments t o be made  situation  there  i s  On t h e one  responsibilities are feasts  towards s a c r i f i c e s ,  torn  that  to attend,  bridewealths,  and  39 funerals, the  and  a host of  other expenditures  most v i g o r o u s o f e n t r e p r e n e u r i a l  harambee c o n t r i b u t i o n s and other  hand,  further  i f  into  the  obligations — and  wealth  community  a man  network  because of as  —  one  and  of  spirits  school tuitions  works i n  few  i s bound  to  choose  another;  or,  difficult  and  one  as i s  of  Whatever t h e  position,  the  fees. is  drawn  t h e more  parent,  powerful,  ancestor,  workers  imperatives compelled they  of the  to  owe.  social he  may  between b o t h  redeem him  from  an  responsibilities,  is  —  and  obligations;  6 7  In —  economies,  a work, an  of the  or  by  a simple  a  commodity.  awareness of s e l f moral  participation i n  system:  over  relation whether a  or the  the  series social  be  compelled  moral  person  of the debts  ever-expanding  non-equivalent  service,  parts  or h e r s e l f  may  systems.  deity, 6 8  to  negotiate a  person i n s o c i e t y  itself  the  relations  they  I n complex e c o n o m i e s , i t i s p o s s i b l e t o  oneself  rendered  community  in  With t i m e , he  spirit,  even  his allegiance  non-reciprocal o t h e r  guardian,  the  of p r e s t i g e  to continuously discharge debts of o b l i g a t i o n . to  On  position  o f t e n the case,  precarious balance  f o r example  community  to question  system  test  and  salaried  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 . forced  and  village  relative  the  —  t h e town and of  his  t h a t would  of  is feel  insulate debts,  r e l a t i o n s can  be  payment o f  money f o r a  Yet i n  subsistence  i s refracted  through a l l  relations  to  subsistence a c t i v i t i e s ,  a  clan  members,  w i l l i n g n e s s to  40 proffer  a valuable service,  principles  of the  community  measure o f t h e man As  our  studies  the  wisdom  work  competing  In the f a c e of  one  discrimination;  Burridge  which refers  to  the  peasant  moral  systems,  There  are, for  traditional  and t h e a t t r a c t i o n  and  how  this  of s a l a r i e d  o r g a n i z a t i o n s of support  these contingencies,  directions to  of  in  t h e message o f t h e m i s s i o n a g a i n s t  t o clan-abased  care.  determine  conflicting  requirements  of the e l d e r s ,  in relation  of  by  persons  and r e l a t i o n s o f power.  bureaucratic obligations, the  a l l contribute  suggest,  are constrained  sources of t r u t h , example,  life  to the c e n t r a l  o r woman.  case  situations  and an a d h e r e n c e  i ti s and  possible  the problem i s t o know  possibilities  process  as  and  and t o  are  ;  true.  characteristically  religious; The redemptive process indicated by the activities, moral rules, and assumptions about power which, pertinent to t h e moral o r d e r and taken on f a i t h , not only enable a people to 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 a r e i n d e e d p e r c e i v i n g the t r u t h o f t h i n g s . 6 9  The in  Community  H e a l t h W o r k e r s {CHWs), and o t h e r s l i k e  t h e community,  particular themselves power complex  —  exemplify  assumptions "betwixt i.e..  bureaucratic  process of  power.  and between"  the dual  economies,  relationships,  of  this  reciprocal  p a r t - t i m e and f u l l - t i m e  expectations,  responding to  Whereas  conflicting  requirements  them  they relations  of s u b s i s t e n c e  find of and  and  non-reciprocal  work,  c l a n - b a s e d and  and s p i r i t u a l  and  professional  41 goals  —  7 0  they  have  responded  to  CBHC a s  an e v e n t  r e l e a s e s them o f t h e s e a p p a r e n t  t e n s i o n s and causes  transcend  i n a  these  worthwhile associated even  difficulties  manner.  so,  i t contains  they  The  in  the t r u t h  their  appreciation  work  of  word  discernible  the perception  of r e a l i t y  and  position  Community H e a l t h  work a s a m a n i f e s t a t i o n o f t h e i r  their  necessary  place i n C h r i s t i a n  Ministry  position  as  an  worthwhileness. constructions of terms of  of  Health p i l o t  expression  as  of  worthwhileness,  power and o f t r u t h ,  social  healer;  spiritual  community;  Project  revitalized  Programme  " g i f t s " and  w h i l e t h e CHWs  professional  relations  and  and  o f these  situated  their medical  separate  a s they  are i n  epistemologies of  i s the relationship that  I will  seek t o  provide as theethnographic  explanation of this thesis.  Burridge  anthropological  explains,  the  endeavour  indicate: . t h e 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 p e o p l e , e v e n t s , a n d t h e f o r m s a n d modes by which t h o s e e v e n t s a r e a r t i c u l a t e d a n d made communicable by rationalizations, inteliectualizations, and symbolic representations. 7 1  the  legitimate  programme c o n s i d e r  The phenomenology o f e a c h  differing  a  or t r a d i t i o n a l  their  the  but  the  B u r a l H e a l t h Development  t h e nyamrerua  CHWs i n t h e N a n g i n a  in  experiences  have come t o a p p r e c i a t e .  CHWs i n t h e S a r a d i d i  consider  and a  o f worthwhileness,  one  and  them t o  respectable  are differing  with the r a t i o n a l i z a t i o n  manifestations of that  There  that  as must  42 1.4.3  Person,  Special  Individual,  persons ( i . e .  accomplish  the  mediation  o r cunning  the events  as they  are presented,  the  a s they  experience  them.  They succumb  titles  instead  o f s t a t u s and r a n k .  to the categories, Individuals,  have s e e n  being  Unlike other  persons,  revitalize, individuals,  i n this  and change e x i s t i n g there  moral  message  s e t before roles,  orders  (.a m e t a n o i a ) , and to social-cultural  i s compelled moral  a r e moments  orders.  when t h e y  7  p r o c e s s c a n be i n d i c a t e d  this  way:  with  to c r i t i c i z e , 7 2  But then f o r  are persons  Yet i f some people a r e wholly i n d i v i d u a l s and others a r e persons, i t i s a m a t t e r o f common o b s e r v a t i o n t h a t most p e o p l e a r e 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 individuals. And t h i s apparent o s c i l l a t i o n or movement between p e r s o n and i n d i v i d u a l — whether in a particular i n s t a n c e t h e 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 indi vid u a l i t y . 3  74  hand,  because  well:  This  and  men and women who a r e c o n t e n t  the i n d i v i d u a l  of  relate  on t h e o t h e r  and come t o b e l i e v e  related  to  do n o t h a v e t h e  i t to the r e a l i t y  of  realities.  negotiations  a n d i n so d o i n g ,  of transcending available  concomitantly,  needed  f o r what i t t a k e s t o s e i z e  are capable what t h e y  and  I n most i n s t a n c e s , p e r s o n s  imagination,  truth  are  individuals)  necessary  separate worlds. vision,  and I n d i v i d u a l i t y  as  43 In  Someone,  No  One;  Burridge successfully  An E s s a y on  elucidates  lQ.diyidualt__,  Kenelm  t h e moments o f t h i s  process  between person and i n d i v i d u a l . of  prophets, mystics,  how  i ti s  that  directions  He e x a m i n e s t h e l i f e - w o r l d  and c h a r i s m a t i c  they  are able  o f change.  It  t o move  spiritual  myth-dreams) these  to available  7 5  perceived  opposing  truths  truths  worlds  (self/others) + —> individual  are able  dreams,  moralities  —  transcend  and m o r a l i t i e s .  elements of t h i s c r i t i c a l  they  certain to  o f b e l i e f and e x p e r i e n c e  (from  and  and i n d i c a t e s  people i n  i s because  articulate specific integrations relating  leaders,  myths,  that  the  they  certify  +  of  identifies  and r e f l e c t i v e p r o c e s s t h i s  [self/moralities)  and  discrepancies  Burridge  —  the  way:  (self/truth)  7 6  Burridge s  thesis  1  on  the  a p p r o p r i a t e and c o g e n t framework the  Community H e a l t h Worker  programmes have emerged avoided  (like  Harambee  government c o n t r o l s promising for and  for  sustained  by  infrastructures programmes  to  communication, care  explaining  as e v e n t u a l i t i e s programmes  that  that  and a d m i n i s t r a t i o n ) ,  this sort  be  t h e work o f  and e n c o u n t e r  infrastructure,  are  linked  and i s  through  leaders  as  innovative, health  care  there  for  dialogue,  between r e p r e s e n t a t i v e s and  to  Nevertheless  viable,  imperative  constructed  CBHC  or interpreted  members  the  an  c a n e i t h e r be  and growth.  t o remain  community  alike,  provides  (CHW) i n CBHC programmes.  domains o f development  programmes o f  health  individual  in  o f the  t h e community  44 itself.  Unfortunately,  dubbed  harambee,  development  "from  "community-based")  programmes  below,"  usually  result  (whether  "broad-based," in  some  pattern  or of  domination/subordination,  opposition/cooperation,  infrequently  programme o f c o m p l e m e n t a r i t y o f  services,  i n an e f f e c t i v e  work,  and agreements.  system that i n t e r v e n e s imposes i t s w i l l and  "target"  and  and p u r p o s e s  by  threatening  now  to  be  Community  their  creating  described  as  axioms  Workers  CHWs  to  of  truth  realities,  have s e i z e d  cases  (CHWs)  and g u a r d i a n s ) of  these  dissatisfied  to  impinging  every  the  extent,  and  related  and d e l i b e r a t e l y These  ordinary  opportunity  3),  t o some  power,  with  and  universes  transcending, and  2  have,  moral  situations for living,  community.  and dilemmas,  I n t h e CBHC programmes t h a t a r e  conflicting  who,  the  orders i n spite  (especially  individuals  authentic  that  f o r charismatic individuals  l e a d e r s , prophets,  realities.  these  work  apparent oppositions  social  Health  negotiated  model f o r d e v e l o p m e n t  on t h e members o f " r e c i p i e n t "  opportunity  [religious  create authentic and  these  i s always the  leaders  some  i s such i t i s u s u a l l y the  communities.  Constrained there  with  and  CHWs a r e  and p r e d i c t a b l e  to create  relating,  new a n d  and w o r k i n g i n  45 ENDNOTES I n Gender (New Y o r k : P a n t h e o n Books, 1982},. e s p . pp. 5-6, I v a n I l l i c h b u i l d s on the s t u d y o f 'key words* p o s i t e d by Raymond W i l l i a m s , Key-Words; 4 Vocabulary, o f C u l t u r e and S o c i e t y (Sew Y o r k : O x f o r d U n i v e r s i t y P r e s s , 1976). 'Community-based h e a l t h c a r e ' (CBHC) i s a k e y word i n t h e sense that i t identifies and imputes a specific c o n s t e l l a t i o n o f n e e d s 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,' a n d 'consumer* a r e c o n s i d e r e d t o be key words. Kenelm B u r r i d g e e x a m i n e s t h e moments o f t h e i n d i v i d u a l and t h e p e r s o n , and t h e movements between them, i n Someone, No One: An E s s a y 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 theoretical c o n t r i b u t i o n to t h i s study i s treated more f u l l y below. UNICEF/WHO J o i n t Committee on Health Policy, National Decision-making f o r Primary Health C a r e (Geneva: World H e a l t h O r g a n i z a t i o n , 1981), p. 47. Using examples from t h e Sudan, the United Republic of T a n z a n i a , t h e R e p u b l i c o f Ghana, I n d i a and S.E. A s i a , F.J.; Bennett reviews the diverse strategies employed i n the implementation of PHC programmes i n " P r i m a r y H e a l t h Care and D e v e l o p i n g Countries," Social S c i e n c e and Medicine, 13A (1979), pp. 505-514. A. Benyoussef r e v i e w s the, s i t u a t i o n o f CBHC programmes — o r what he c a l l s " b a s i c " health care — i n C h i n a , T a n z a n i a , V e n e z u a l a , I n d i a , Cuba,, N i g e r , and I r a n , i n " H e a l t h C a r e i n D e v e l o p i n g C o u n t r i e s , " S o c i a l S c i e n c e and M e d i c i n e , 11 ( 1 9 7 7 ) , pp.,399-408. More specifically, V i c t o r W» S i d e l and Ruth S i d e l e x a m i n e t h e relationship 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 t o Sweden, Britain,, the Soviet Union, the U.S.A., C h i n a , and C h i l e , in "Primary Health Care in Relation to Socio-Political 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 ( 1 9 7 7 ) , pp. 415-419. For a very brief overview of the relative differences 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 R e g i o n s , " 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 o f t h e World H e a l t h 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 International C h i l d r e n ' s Emergency F u n d , P r i m a r y H e a l t h C a r e : Report of the International Conference on Primary Health Care (Geneva and New Y o r k : World H e a l t h O r g a n i z a t i o n , 1978), pp. 2-3. Quoted f r o m Conferences  t h e WHO/UNICEF "Report o f the I n t e r n a t i o n a l on P r i m a r y H e a l t h C a r e " (ICPHC/ALA/78.10.), i n  46 F.J. Bennett, "Primary Health Care C o u n t r i e s , " S o c i a l S c i e n c e and Medicine, 505.  in 13A  Developing (1979), p.  6  World H e a l t h Organization, Primary Health Care," WHO 409-430..  "The Alma-Ata C o n f e r e n c e Chronicle, 32 (1978),  7  C f . , UNICEF/Who J o i n t Committee on H e a l t h P o l i c y , M a t i o a a l , Decision-making f o r Primary Health C a r e (Geneva: World H e a l t h O r g a n i z a t i o n , T98177  8  T h i s was t h e d e c i s i o n o f t h e f o u r t e e n t h p l e n a r y m e e t i n g o f t h e World H e a l t h O r g a n i z a t i o n , 19 May 1977, and g u o t e d i n : World H e a l t h Organization, "The Alma-Ata C o n f e r e n c e on P r i m a r y H e a l t h C a r e , " WHO C h r o n i c l e , 32 ( 1 9 7 8 ) , p. 429.  9  World Health Organization, Basic (Geneva: W o r l d H e a l t h O r g a n i z a t i o n ,  Documents, 26th 1976), p. 1.  1 0  World H e a l t h Organization, Primary Health Care," WHO 428-429..  1 1  Ibid.; cf. as w e l l : Aga Khan F o u n d a t i o n and World Organization, The Role of Hospitals i n Primary Care (Geneva: Aga Khan F o u n d a t i o n and World O r g a n i z a t i o n , 1981).. World H e a l t h Organization, Primary Healthcare," WHO 428-429.  "The A l m a - A t a Chronicle, 32  "The A l m a - A t a Chronicle, 32  on pp.  ed.  C o n f e r e n c e on (1978), pp. Health Healthj Health  C o n f e r e n c e on (1978), pp.-  1 3  World H e a l t h Organization, "The A l m a - A t a Conference P r i m a r y H e a l t h C a r e , " WHO. C h r o n i c l e , 32 ( 1 9 7 8 ) .  i*  0NICEF/WHO J o i n t Committee on Health P o l i c y , National; Decision-making f o r P r i m a r y H e a l t h Ca^re (Geneva: World H e a l t h O r g a n i z a t i o n , 1981), p. 48.  *  R.B. Isely, " R e f l e c t i o n s on an E x p e r i e n c e i n Community Participation in Cameroon," A n n a l e s de 1 | Soc.ie.te bel,g§ de Medecine t r o p i c a l e , 59 (1979), S u p p l . , p . 112.  s  on  See as w e l l : Raymond B. I s l e y and J e a n F . Martin, "The Village Health Committee: Starting Point for Bural D e v e l o p m e n t , " 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. S a n w o g o l , and J e a n F. M a r t i n , "Community Organization as an Approach to Health Education in Rural Africa," International Journal of. Health Education, Supplement to XXII, I s s u e No., 3 7 J u l y - S e p t e m b e r " 1 9 7 9 ) , pp. 1-19. 0NICEF/WH0  Interregional  Study and  Workshop,  Primary  47 Health Care: The Community H e a l t h C a r e Worker ( K i n g s t o n , Jamaica: World Health Organization and U n i t e d Nations I n t e r n a t i o n a l C h i l d r e n ' s Emergency f u n d , 1979/1980), p.. 9. *  7  D. B a n e r j i , "The S o l e o f H o s p i t a l s i n P r o m o t i n g a n d U s i n g Community P a r t i c i p a t i o n i n t h e Development o f Primary Health Care," I n Aga Khan F o u n d a t i o n and World Health Organization, The S o l e o f H o s p i t a l s j_n. P£iaar.y_ Health. £a££ (Geneva: Aga Khan F o u n d a t i o n and World Health O r g a n i z a t i o n , 1981) , p . 34.  1 8  Daniel Flahault, "The R e l a t i o n s h i p Between Community H e a l t h Workers, t h e H e a l t h S e r v i c e s , and t h e Community," WHO C h r o n i c l e . 32 ( 1 9 7 8 ) , p . 150..  1 9  J o h n II. B r y a n t , "Community H e a l t h Between Communities and H e a l t h C h r o n i c l e , 32 ( 1 9 7 8 ) , p . 145.  W o r k e r s : The I n t e r f a c e Care Systems," WHQ  2 0 f o r an e x p l a n a t i o n of this useful notion i n the l i t e r a t u r e o f medical anthropology, see: Arthur Kleinman, "Family-Based Popular Health Culture," In Patients and Healers i n the Context of Culture: An E x p l o r a t i o n o f t h e B o r d e r l a n d Between A n t h r o p o l o g y , M e d i c i n e , a n d P s y c h i a t r y ( B e r k e l e y : t h e U n i v e r s i t y o f C a l i f o r n i a P r e s s , 1 9 8 0 ) , pp. 179-202. 2  *  2  2  F o r 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 Africa, see: J.R. Weisz, "East African Medical A t t i t u d e s , " S o c i a l S c i e n c e and M e d i c i n e , 6 (1972), pp. 323-333. F o r two p e r s p e c t i v e s ~ o n " * t h e ~ i n c o r p o r a t i o n o f traditional medical s y s t e m s 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 t h e Background o f Changing H e a l t h Care Concepts i n Africa," S o c i a l Science and M e d i c i n e , 13B (1979), pp. 175-182; and, David W. " " D u n l o p , "Alternatives t o 'Modern* H e a l t h Delivery Systems i n Africa; public Policy Issues of Traditional Health Systems," S o c i a l S c i e n c e and M e d i c i n e , 9 (1975), pp. 581-586. S e e ; S j a a k Van D e r G e e s t , Primary Health Care i n Medicine, and P s y c h i a t r y ,  365-3837  2  3  2  *  "The S e c o n d a r y I m p o r t a n c e o f South Cameroon," Cultuj-e. 6: 4 (December 1982) ,~ pp.  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,. J a m a i c a : World H e a l t h O r g a n i z a t i o n a n d t h e 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 F u n d , 1 9 7 9 / 1 9 8 0 ) , e s p . p. 35. Cf.  UNICEF-WHO J o i n t  Committee  on H e a l t h  Policy  Report,  48 Community I n v o l v e m e n t i n Primary. Health, C a r e : A S t u d y of the Process of Community Motivation and Continued P a r t i c i p a t i o n (Geneva: World H e a l t h O r g a n i z a t i o n , 1977), e s p . p . 10. 2s  George F o s t e r , "Community Development and P r i m a r y H e a l t h Care: Their Conceptual Similarities," Medical; A n t h r o p o l o g y , 6 ( 1 9 8 2 ) , p . 192.  2  6  R.B. Isely, " R e f l e c t i o n s on an E x p e r i e n c e i n Community P a r t i c i p a t i o n i n Cameroon," A n n a l e s de l a S o c i e t e b e i g e de M e d i c i n e t r o p i c a l e , 59 (1979), S u p p l . , p . 114.  2  7  See: Frank Hoimquist, S e l f - H e l p i n Kenya and (1976), p. 7.  2  8  Jomo K e n y a t t a , * Harambee!' The Speeches 1963-1964 [ N a i r o b i : 1964) , p. 7.  "Class Structure and Rural Tanzania," A f r i c a n Review, 6:2 Prime M i n i s t e r of Kenya's Oxford U n i v e r s i t y Press,  29  F o r t h e e t y m o l o g y o f harambee i n t h e p o l i t i c a l economy o f the R e p u b l i c of Kenya, see: J o h n H.O., O r o r a a n d 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 in Kenya," International Journal of Comparative, S o c i o l o q y , XXI: 3-4 ( T 9 8 0 f 7 ~ s p . p."244.  30  see: Martin H i l l , "The 34:689 (1975) , p. 644.  31  P.M. M b i t h i and R. Rasmusson q u o t e d i n : J o h n H.O. Orora a n d 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 ( 1 9 8 0 ) , p. 244.  32  See: E.M. G o d f r e y and G.C.M., M u t i s o , "The P o l i t i c a l Economy o f 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 Studies, 8:1. (1974), pp. 109-133.  33  See: Martin H i l l , 34:689 (1975), pp.  3*  Ibid.,  Roots  Society,  o f Harambee," New  Society,  This information i s also confirmed in a interview with the S e n i o r Health Care Planner, o f H e a l t h h e a d q u a r t e r s , N a i r o b i , Kenya.  personal Ministry  p.  "The Roots 644-646.  o f Harambee," New  646.  3  5  See; J o h n H-0« O r o r a 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 o f C o m p a r a t i v e S o c i o l o q y , XXI:3-4 ( 1 9 8 0 ) , 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 , a n d R u r a l S e l f - H e l p , " I n J o e l D. B a r k a n (ed.) w i t h John, J . ... Ok urn a, golitics and P u b l i c P o l i c y , i n Kenya and T a n z a n i a (New Y o r k , L o n d o n , Sydney, and T o r o n t o : P r a e g e r P u b l i s h e r s , 1979), p . 139. See a s w e l l : S.E. P o l i c y and E g u a l i t y , "  Migot-Adholla, "Rural I n i b i d . , e s p . p. ,163.  Development  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 a n d T a n z a n i a , " A f r i c a n Review, 6:2 ( 1 9 7 6 ) , e s p . p . 248.  3  9  E . M» G o d f r e y and G.C.M. M u t i s o , "The P o l i t i c a l Economy o f Self-Help: K e n y a ' s "Harambee" I n s t i t u t e s o f T e c h n o l o g y , " C a n a d i a n J o u r n a l o f A f r i c a n S t u d i e s , 8:1 ( 1 9 7 4 ) , p . 121.  4  0  Henry B i e n e n , K e n y a : The P o l i t i c s o f P a r t i c i p a t i o n and Control (Princeton, New J e r s e y : Princeton University P r e s s , 1 9 7 4 ) , p p . 42-43.  *i  Victoria Brittain, "Five Months T h a t Took Kenya B r i n k , " The G u a r d i a n , 8 August 1982, p. 7.  To The  4  2  J o h n J . Okumo, " P a r t y a n d 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. B a r k a n (ed.) w i t h J o h n 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 a n d T a n z a n i a (New Y o r k , London, Sydney, a n d T o r o n t o : P r a e g e r P u b l i s h e r s , 1979), p . 57.  4  3  Henry B i e n e n , Kenya; The P o l i t i c s o f P a r t i c i p a t i o n a n d Control [Princeton, New Jersey: Princeton University Press,"~1974) , p . 141; s e e a s w e l l p . 2 9 .  4  4  See: E.g. G o d f r e y and G.C.M. Mutiso, "The P o l i t i c a l Economy o f 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 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 writings of these i n f l u e n t i a l Luq leaders; Tom Hboya, Freedom and A f t e r [London: Andre, Deutsch, 1963) ; a n d O g i n g a O d i n g a , Not Y§.t Uhuru: An A u t o b i o g r a p h y ( L o n d o n ; Heinemann, 1 9 6 7 ) . ,  4  6  J o e l D. B a r k a n s u g g e s t s t h a t ; development i s an i n h e r e n t l y ethical phenomenon, a s e t o f v a l u e j u d g e m e n t s a b o u t what constitutes the good society and about t h e i n s t i t u t i o n s and p r o c e s s e s t h r o u g h which t h e good s o c i e t y c a n be a c h i e v e d . See: Joel 0. B a r k a n , "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 T a n z a n i a , " I n J o e l D. B a r k a n (ed.) w i t h J o h n 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 T a n z a n i a (New Y o r k , London, P r a e g e r P u b l i s h e r s , 1 9 7 9 ) , p . 12. 4  and T o r o n t o :  S e e : John J , Okumu, " P a r t y 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.) w i t h J o h n 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 T a n z a n i a (New Y o r k , London, Sydney, a n d T o r o n t o ; P r a e g e r P u b l i s h e r s , 1 9 7 9 ) , p . 5 9 .  7  *  Sydney,  8  See: V i c t o r i a B r i t t a i n , " F i v e Months T h a t Took Kenya To The B r i n k , " The G u a r d i a n . 8 August 1982, p . 7. In July o f 1982 t h e e d i t o r o f Thje. S t a n d a r d , a Kenyan newspaper, was f o r c e a b l y dismissed f o r publishing an editorial c a l l i n g on t h e Government to release those p e r s o n s who have been d e t 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 s u b s e q u e n t l y r e p u b l i s h e d i n : George G i t h i i , " S p e a k i n g O u t Of T u r n I n Kenya," T h e Guar_dian, 1 A u g u s t 1982.  5  0  S e e : P h i l i p M. M b i t h i , "'Harambee; S e l f - H e l p : A p p r o a c h , " The Kenyan Review, 2:1 (June 1 9 7 2 ) ,  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 , a n d R u r a l S e l f - H e l p , " I n J o e l D. B a r k a n (ed.) w i t h John J. Okumu, Politics and P u b l i c P o l i c y i n Kenya and T a n z a n i a [Mew Y o r k , L o n d o n , Sydney, and T o r o n t o : P r a e g e r P u b l i s h e r s , 1 9 7 9 ) , p . 131.  1  The Kenyan pp. 1 5 7 f f -  s z P h i l i p M. Mbithi, "'Harambee:' S e l f - H e l p : The Kenyan A p p r o a c h , " The A f r i c a n Review, 2:1 (June 1 9 7 2 ) , p . 160. 53  Ibid.  s* I b i d . ,  pp. 155-156.  ss I b i d . ,  p p . 158-161.  5  6  Miriam K. Were, "Rural Women's Community-Based Health Care," East J o u r n a l , 54:10 ( O c t o b e r 1977), p. 5 2 9 .  Perceptions and African. Medical  5  7  S e e : P.M. M b i t h i , " I s s u e s i n R u r a l Development i n Kenya,'»• E a s t A f r i c a J o u r n a l , 9:3 (March 1 9 7 2 ) , pp. 18-22. ..  5  8  S e e : Kenelm B u r r i d g e , Mambu [London: Methuen, 1960) ; Hew Heaven, New E a r t h (Oxford; B a s i l Blackwell, 1969) ; Encountering Aborigines (London a n d New York: Pergamon P r e s s , 1 9 7 3 ) ; 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  A r g u i n g t h a t one must s e l e c t a v a n t a g e - p o i n t f r o m w h i c h t o view the t o t a l i t y of a culture, Elkana claims that "science" i s t h e most important dimension of Western culture; s e e : Yehuda E l k a n a , "A P r o g r a m m a t i c A t t e m p t a t  51 an A n t h r o p o l o g y o f Knowledge," I n E v e r e t t M e n d e l s o h n and Yehuda Elkana (eds.) Sciences and Culture: 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 Studies of the Sciences (Dordrecht, Boston, and London: D. Eeidel Publishing Company, 1981), e s p . pp. 8 f f . 6  0  6  *  Kenelm B u r r i d g e , someone, Mo One { P r i n c e t o n , 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. 92. Ibid.,  New  Jersey:  p. 93.  *z I b i d . ,  pp.  93-94.  «3 I b i d . ,  p. 97.  ** I b i d . ,  pp. 95-96;  s e e a s w e l l p...188.  A d i s t i n c t i o n between t h o s e s o c i a l o r d e r s w h i c h do o r do n o t use money i s a l s o p r o v i d e d i n : Kenelm B u r r i d g e , fle.w. Heaven, New Earth (Toronto: The Copp Clark Publishing 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 , 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.  New  Jersey:  66  Ibid.,  67  on r e l a t i o n s h i p s w i t h t h e 'non-reciprocal other,' see i n particular: Kenelm B u r r i d g e , " L e v e l s o f B e i n g , " i n Gene O u t k a and J o h n P. B e e d e r Jr» (eds.), R e l i g i o n arid; M o r a l i t y (New Y o r k ; A n c h o r Books, D o u b l e d a y , 1 9 7 3 ) . ,  68  s e e : Kenelm B u r r i d g e , New Heaven, New E a r t h Copp C l a r k P u b l i s h i n g Company, 1969), p. 6.  69  Ibid.,  pp.  pp.  105-106,  *  7  2  7  3  7  *  7 5  e s p . p.  144.  Kenelm B u r r i d g e , Someone, No One ( P r i n c e t o n , 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. Ibid.,  New  Jersey:  p. 5.  Ibid. Ibid.,  p. 74.  Burridge  The  6-7.  *o S e e : I b i d . , 7  (Toronto:  e x p l i c a t e s 'myth-dream*  this  way:  As a c o n c e p t 'myth-dream' d o e s n o t l e n d i t s e l f t o precise definition. Nevertheless, myth-dreams exist, and t h e y may be r e d u c e d to a series of themes, p r o p o s i t i o n s , and p r o b l e m s which a r e t o be  52 f o u n d i n myths, i n dreams, i n the h a l f - l i g h t s of conversation, and i n t h e e m o t i o n a l r e s p o n s e s t o a v a r i e t y o f a c t i o n s , and g u e s t i o n s a s k e d . , Through this kind of intellectualization myth-dreams become ' a s p i r a t i o n s ' . . . . . .. s u c h i n t e l l e c t u a l i z a t i o n s as a r e made may become the definitive principles upon which a group o f p e r s o n s may organize themselves into a viable party o r 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 position from which i t may 'capture' the myth-dream by s y m b o l i z i n g and putting into effect the propositions contained i n the myth-dream. H a v i n g done s o , h a v i n g c a p t u r e d what a p p e a r s a s a mainspring of community action, the group concerned may harness this power to serve a community o r 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; Methuen, 1960), p . 148. 7  6  a Melanesian M i l l e n i u m  Kenelm B u r r i d g e , Someone, No One [ P r i n c e t o n , 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.  New  (London; Jersey;  Chapter THE PROBLEM OF THE CASE OF THE  2.1  II  "COMMUNITY-BASED HEALTH CARE": MINISTRY OF HEALTH, REPUBLIC OF KENYA  INTRODUCTION "To the community t h e Community (CHW) i s t h e i r l o c a l doctor"» Of  the t h r e e  Ministry  of  ethnographic cases  Health  of implementing in  illustrates  mutually  CBHC programmes.  authentic, was  situationally  posited  exchange of  that  a  ideas  be  s o c i a l systems:  that  clinical  communicated  the  leaders  shown  that  the  ground  In  and  the  currently  in is  fertile  s e l f - s u s t a i n i n g CBHC  case  of the  implemented  the  community  possibilities for  53  in  representatives  3  a  referral 4,  i t  a  dialectic  is  the  emergence  of  Health's  projects  c o n s t r u c t i n g v i a b l e and  -  two  and  programmes.  M i n i s t r y of pilot  for  as  democratic  between the  and  where  care  emerge  or  In c h a p t e r s  contexts  problem  health  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  will  enduring  of  implemented,  CBHC programme.„  tolerated  the  the  strategies, i t  encounter  b a c k - u p f o r the be  thesis,  systems of  h e a l t h care  dialogue,  of  this  programmes t o  relevant  w h i c h a programme i s t o be of the  CBHC  freely  in  Worker  most d r a m a t i c a l l y  supportive For  Health  -  in  proposed CBHC,  mutually  and the  suppqrt  54 CBHC programmes eventuality the an  are l i m i t e d .  to explain  (i)  reconstruct  the  development  delineate  emerge i n  a  CBHC  strategy.  of Health's  response  implement  have  CBHC  the  strongly  government's the actual  CBHC model  i s l e s s than  urged  opposition  just  be  t o the r i g i d i t y  attributed  bureaucratic culture  research,  plans this  s t r u c t u r e and t h e  that  will  t o the  and  donor  officials and call  to  proposals. has  and r e c e p t i o n I suggest  been  o f the  t h a t the  t o t h e CBHC s t r a t e g y  applauded  be  (CHW).  by h e a l t h  and e s s e n t i a l h e a l t h care  of biomedicine  biomedically  care  encouraging.,  managers a s a  The p r o b l e m s  Kenyan  interpretation  though i t i s r h e t o r i c a l l y  e f f e c t i v e n e s s of  Worker  response to  r e s i s t a n c e and u n d e r l y i n g  and ( i i ) ,  r u r a l communities  aid,  i n future health  I will:  CBHC programmes  Community H e a l t h  favourable,  even  of  care,  In  c u l t u r e and e p i s t e m o l o g y o f  health  care  within  chapter.  policy,  the p o t e n t i a l  International health  While  national  threatens  i n the  organizations  by o f f i c i a l s  s e t t i n g and b a c k g r o u n d f o r  the government-directed  manifested  and t h e  and i n t e r p r e t t h i s s i t u a t i o n ,  of  that  problem  examine i n t h i s  the bureaucratic  supplementary  Ministry  that I  the lineaments of the  health care this  i s this  o f CBHC a s i t i s p e r c e i v e d  2  Ministry o f Health attempt  It  tactic  of the M i n i s t r y  of  —  care_ —  can  Health's  predominant i n f l u e n c e o f the  ( a c t u a l i z e d i n t h e power  trained professionals).  wielded  by  55 These t h r e e —  ideology,  all  play  bureaucracy,  a significant  Whereas some of  perspectives  implementation  part  i n explaining the  i n f l u e n c e s and  the  biomedicine  symbols  encourage t h e g o a l s  notion  o f CBHC.  philosophy the  of  Harambee  development  of  e f f o r t s of  rural  emphasizes  community  a l s o i n accord (PHC)  or  CBHC  significantly, traditional, unique That  is,  they  by  professional  goals,  involvement  and n u r s e s  i n charge  the  with  upon by  and  Primary and  Health  i s Care Most  t h a t i n Kenya  itself,  health  been i n v o l v e d i n care"  a l l  on community-derived and i l l n e s s e s  of  along.:  therapeutic experienced  administrators,  underscores a l t e r n a t i v e Within  which  ONICEF.  c o m m u n i t i e s have  commitments  —  participation —  WHO  i s the f a c t  self-reliant  Harambee  t h e r e s o l u t i o n s on  and o b j e c t i v e s .  administrators  through  the pathologies  The  i s no p r o b l e m  communities.  relied  members.  physicians,  the nation  "community-based  their  (ideology).  argues f o r  rural-based  structures t o heal  legitimate  ( s e l f - h e l p development)  however,  have  certain  and economic  agreed  forms, o f  there  their  prevailing political  peasant  with  economy  and o b j e c t i v e s o f CBHC  The  with  and b u r e a u c r a c 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 , the  development  respects  i n the p o l i t i c a l  —  CBHC drama.  authentic  a n d compete i n some  (e.g.,  between them  and t h e c u l t u r e o f b i o m e d i c i n e  relations constrain  CBHC programmes  and  and t h e r e l a t i o n s  emphases,,  the Ministry o f Health,  of health care  policy  the  are usually  56 professionally rooted  in  committed  trained  the  scientific  to a c l i n i c a l  When c o n f r o n t e d commitment t o bias.  physicians.  with CBHC,  the  bureaucratic Health. controlled)  of  of  (at the CBHC.  physicians,  the  ideas  alternative  culturally  Ministry  an  of  t o the  predicated well  community  Ministry  a dialogue  of  rigid  and and  Western-Strained and  implement  to  (and  innovative  and  exchange  With  of  harambee  to respond e f f e c t i v e l y tribal,  c a r e needs. the  of  incapable  principles  unfold  responding  the  (centrally  i t i s structurally  unable  variability  to d i m i n i s h  scale  wisdom.,  the  perspectives.  health  of  the  by  H e a l t h can  was  for a  a national  organizationally  from e n t e r t a i n i n g  government  and  clinical  of H e a l t h i s  time)  d e b a r r e d from  or  precisely  this  care  are  perspective,  top-heavy  Controlled  strategies,  and  care  within  c a r e s t r a t e g i e s , but  programmes, t h e  biomedicine  biomedical c o n t r o l s i s  present  Ministry  organizationally)  on  health  of  It is  structure.  health  on  administratively  inflexible  existing  and  they  donor a g e n c i e s  planned  controls  bureaucracy, the  of implementing objectives  are  t h i s system  an  health  large  c u l t u r a l appreciation  structure  As  of  demands o f  self-determinism,  A c o r o l l a r y of  and  t h e i r response r e f l e c t s  s o c i a l and  incentives,  tradition  (curative)  CBHC programmes  without the  By  t r u s t and  ethnic*  and  CBHC programmes  promise  as  faith  wananchi  (average c i t i z e n ) i n t h e i r government.,  of  the  57 As  such,  being  the  model f o r CBHC programmes t h a t  formulated  within  bureaucratically  heavy  administration.  It  government  care  level  health  of the  system  Community H e a l t h  [i.e.  select  them —  would be  the  therefore, part  of  t o extend  —  t r a i n e d and level.  peasant  by  i s not  i.e.,  f r o m a m u t u a l exchange o f  Figure In  this  the  be  chapter, which  are  interpreted  emergent  process  of  communities  who  to  To they  commitment  this  kind  members o f  of  and  the  i t s headquarters  of  rural  would p r e f e r ideas  extension  and  government  i t  —  systems  of  government's  i n Nairobi  (see  3) .  relations, will  programme.  system from  Ministry  not  peasant communities  another  peripheral  s u r p r i s i n g to  this  health care  the  the  of  It i s  communities,  rather  network  by  CBHC  s u p p o r t —• b u t  in  supervised  government-inspired  derived  dominant  communities)...  understanding  CBHC as  is  most  whom  remunerated  Health  the  the  rural-based  a lack of  rural  into  (CHWs)  District  of  biomedically  workers  s u g g e s t s would be  on  Ministry  proposes  Health  witness,  and  Workers  p e r s o n n e l at the  the  i s currently  of  view o f  these  refracted i n  t h r o u g h the the  construction  conceptualization,  underlying  MOH  the  person of  process on  of  CBHC.  i n t o the  (iii)  o f a n a t i o n a l CBHC programme.  And  view o f t h e  i s bound t o  Ministry  of H e a l t h  CHW,.  re-constructing  moments  and  yet,  the  I separate  three  ( i i ) organization,  epistemological  this  of  (i),  management  even t h i s change.  apparent As  is  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  A d a p t e d f r o m : The World Bank, Kenya: P o p u l a t i o n and Development ( W a s h i n g t o n , D.C.: Development Economics D e p a r t m e n t , E a s t A f r i c a C o u n t r y Programs Department, The W o r l d Bank, 1 9 8 0 ) , R e g i o n s and Districts  Map.  59 indicated Ministry  i n the of Health  most  this particular  used  in  Ministry  of  policy  t o w a r d CBHC,  with  this  recent  Health  i t is still  h e a l t h care  chapter  is  (and  statements  based  p u b l i s h e d and  personal  until  June o f  2.2  THE CONCEPTUALIZATION OF HEALTH CASE" POLICY  evidence  interpretations  o t h e r Government)  were  the  "experimenting"  s t r a t e g y . * The on  of  3  from  documents t h a t  interviews  that occurred  up  AN  "COMMUNITY-BASED  1981.  INFORMAL  ... the r e s p o n s i b i l i t y f o r t h e improvement of q u a l i t y of l i f e l i e ultimately in the community itself. The most i m p o r t a n t r e s o u r c e i n t h e whole d e v e l o p m e n t drama i s t h e community i t s e l f . . . ... change a g e n t s are short term m e a s u r e s 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 strengthen community i d e a s and i n s t i t u t i o n s . Shis process requires more facts about the reality of community. But facts, must be above a l l , complemented by common s e n s e , imagination and a l o t of i n t u i t i o n . 5  2.2.1  The  Bureaucratic  In t h i s s e c t i o n , i n f l u e n c e the  I  M i n i s t r y of H e a l t h .  may  publicly  reality  to unravel  Even though the  declare i t s allegiance of  of the  Primary  Health Care  health care  o t h e r commitments domain  attempt  the f a c t o r s  c o n c e p t u a l i z a t i o n o f a CBHC  the  objectives  Context  and  of p o w e r f u l l y  programme  within  M i n i s t r y of  Health  to the  principles  (PHC),  the  planning environment  allegiances.  Within  placed individuals  which  and  everyday  communicates  the  strategic  i n the  Ministry,  60 d e c i s i o n s are of  often  stated policy,  made t h a t a r e not  but  rather,  the  so  much a  political  reflection  interest  of  i n d i v i d u a l i n q u e s t i o n , . * T h e r e i s , however, a c e r t a i n of  pressure  to conform  to  prevailing  c o u r s e the economic r e a l i t i e s w h i l e an  upper l e v e l  more o f t h e  distribution  develop  facilities,  may  the country.  a  more  he  may  extensive still  Government tack  w i t h i n the  political  self-reliance in  Kenyatta*s Kenya, his  has  and  the  network  case  Ministry  of  the  well  as  health  particular  m o t i f s and  are  Harambee  motto o f Nyayo  being the Daniel  essential arap  Moi,_  Republic  (Kiswahili  to  Jqmq.  identified  h i s indebtedness  intention  of  compelled  themes.  as P r e s i d e n t o f t h e  his  f o r CBHC  approach.  process.  which d e m o n s t r a t e s  health,  Ministry  of Health  of  is  ministries  a  when t h e  f o r a CBHC  development  static  p r e v e n t i o n and  convinced  philosophy  equal  i f this  to argue  s e l f - d e t e r m i n a t i o n as  propounded  as  of  t r u e when o t h e r  political  named s u c c e s s o r  footsteps")  predecessor  the  to  own  "modern" t h i n g t o do  disease  are  a s was  to consider fundamental  force  allocate  Similarly,  be c o m p e l l e d  Planning argued  Policy-makers  Kenyatta*s  that the  of  o f H e a l t h . , So  a d a m a n t l y v o i c e a commitment  i s convinced  the  and  v i e w s and  have t h e power t o  This i s particularly  development Finance  he  which e m p h a s i z e  promotion. within  manager may  throughout  administrator  programmes  of the M i n i s t r y  amount  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  home D i s t r i c t ,  to  political  the  assert  of  for "in to his similar  61 principles  of  self-reliance  and  Consequently,  Harambee  (Self-Help)  stated  of  present  theme  the  self-help  is  still  government  c u r r e n t d e v e l o p m e n t o b j e c t i v e s and that  self-determination.  goals.  very  much  the  and  influences  It is  understood  processes require  ... a t l e a s t a minimum o f community o r g a n i z a t i o n , involvement, and initiative, and a community c o n t r i b u t i o n o f f i n a n c e and labour, or b o t h , to any p r o j e c t . 7  In t h e r u r a l building centres.  Self-help  8  organize  activities  development. "develop  themselves  at  influenced  by  international of "health at  within the  political  f o r a l l by  a public  policy  encouraged  CBHC  Ministry this  have  come to.  o t h e r words, i n  of  used  peasants level  i n the  Health are  mottos g e n e r a t e d  programmes.  2,000" i s one  philosophy  by  such  of Health o f f i c i a l s ,  policy  for  e c o n o m i c and  planning,  yet,  the  of  decree, Alma-Ata  of s e l f - h e l p ;  H e a l t h C a r e o r CBHC,  And  also  HHO/UNICEF*s o b j e c t i v e  the D e c l a r a t i o n  initiation,  for  amenities.  in  the  governments  are  t o a p p r o p r i a t e t h e human r e s o u r c e s o f t h e i r  communities the  of Primary  year  level,  r e i n f o r c e s Kenya's e x i s t i n g achievement  Ministry  community.  the  community  themselves,"  socially  themes and  health care  In  and  t h e community  p u r p o s e o f a c q u i r i n g p u b l i c and Policy-makers  e v i d e n t i n the  health f a c i l i t i e s ,  to modernize and/or  collectively  p r o j e c t s are  ( o r harambee)  process to achieve  effort  the  self-help  of s c h o o l s , roads,  mean the an  areas,  from  and the  rural  management of  perspective  of  there i s cause t o s u b s c r i b e t o not s i m p l y  political  reasons.  62 In  t h e "development  to  get  ooaSI*  9  &  business,"  t  t  n  p o l i c i e s and p l a n s  present  e  time,  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 influenced  by t h e W o r l d H e a l t h  on P r i m a r y specific  Health  Care  requirements  donors  and  a r e now  and procedures  f o r the Integrated  programme  (IRH-FP),  most  the  of  officials  i n a united  corporately,  Agency  the large  in  developing  Development  Integrated  the  Rural  of  definitely  of donors  sector —  Authority  (DANIDA)  and  the  economic  Family  in  around  States  (USAID),  —  that  traditionally  (SIDA) ,  CBHC i n f r a s t r u c t u r e  Health  Health,  as w e l l as  i . e . United  Development  I n t e r n a t i o n a l D e v e l o p m e n t Agency in  Ministry  The Bank i s i n s i s t i n g  majority  for International  Planning  i s coordinating  Acting independently  Kenya's h e a l t h  International  before the  and F a m i l y  f a s h i o n a n d most  key p r i n c i p l e o f CBHC.  involved  between  that  In the process of  Bank M i s s i o n  and i n t e r e s t e d donors.  donors a c t the  t h e World  been  position  demanding  be f u l f i l l e d  Rural Health  deliberations  (WHO)  1  promise o f economic a s s i s t a n c e i s g i v e n . , planning  and a i d  h e a l t h s e c t o r have  Organization s  (PHC)  a r e made  Swedish  and  Danish,  are interested this  Planning  proposed programme  (IRH-FP) . , Over calling the  and above  f o r an a l t e r n a t i v e  precipitating  itself.  health  and p o l i t i c a l care strategy,  there are  i n f l u e n c e s within the M i n i s t r y  of Health  A number o f r e s e a r c h s t u d i e s c a r r i e d  professionals  influences  employed  by  the Ministry  of  o u t by h e a l t h Health  and  by  63 health the  professionals attached  University  deficiencies One  such  that  of  firm  Nairobi  have  the existing  rural  study c a r r i e d out  preventive  rarely  the  of  used.*  services  rural  they  area  found  research  that  most  of  preventable. Ministry  Health  Organization, situated  in:  Figure  From t h e  (i) the health  the  policy  of  last  services i n this  The most c e l e b r a t e d decade i n  Kenya  afflicting  implied  was  Kenyans  with t h e that  health  suggested  sponsored  were by  World  and ( i i )  of the r e c i p i e n t  the  Health  the problem  system i t s e l f ,  was  i n the  populations  events that  the  officials  recipient  the  population  system.  the s i g n i f i c a n c e  of these  a n d 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.  Health's  In the  Health  of the d e l i v e r y  t o appreciate  economic, of  Ministry of  was t o c r i t i c i z e  the structure  Ministry  programme.  1 1  health  In Kitui  4) .  i s essential  political,  indicates  P r o j e c t of  report that  the r e s u l t s  n a t u r a l tendency  It  District  Development  i n collaboration  perspective  r a t h e r than  system.  Health  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 [see  service  consulting  diseases  In t h i s  of  serious  independent  preventive  o f the  the  health  the  p r o d u c e d t h e same r e s u l t s .  that  study  exposed  by an  were u n d e r - u t i l i z e d .  care  of Medicine at  i n particular are under-utilized or  by t h e R u r a l  Ministry of Health,  Faculty  i n Hachakos  Another study  0  commissioned  District,  to the  conceptualization  chronicle  follows,  1 2  the  of  specific  of  a  CBHC  planning  and  substance and c h a r a c t e r of  F i g u r e 4. Kenya Community Nurse  (KCN)  Photograph o f Kenya Community Nurse (KCN) weighing c h i l d and recording c h i l d ' s  "Road t o H e a l t h "  c h a r t a t the Chulaimbo Ru  Health T r a i n i n g Centre (RHTC) near Kisumu, Kenya  65 the  phenomenal r e l a t i o n s e x p e r i e n c e d  Health  i s displayed  problems w i l l i)  fall  within  more c l e a r l y . along  ^ c u r a t i y e as  these  the  In broad  Ministry  of  strokes,  the  health  care,  health  care  axes:  opposed t o a p r e v e n t i v e  strategy, ii)  an  urban  versus  resources, iii)  a health trends  a rural  allocation  of  and care  and  bureacracy  biodmedical  traditional  by  principles)  medical  subsistence-based  [influenced  systems  and  modernist  impinging  on  [constrained  peasant-based  by  social  organizations) . all CBHC.  of  these r e l a t i o n s  The  actors involved  interests  of  the  communities.. versus  i s not  "community" as to  played  i n the  Ministry  It  m i s u n d e r s t o o d and  are  i n the  drama r e p r e s e n t  of  so  out  Health  or  much a s t o r y  much a s  drama either  rural of  avoids  the  peasant  "bureaucracy"  a s i t u a t i o n . where e a c h  some e x t e n t  of  relations  with  is the  other. Since Health's  this point  perspective: that  of  view,  i.e.,  the  I  that  of c o n c e i v i n g  uncover the  will  of  an  professional,  administrators the  Ministry of  Ministry  concentrate  " p e r s o n a l i t y " of  medical,  upper l e v e l  become c l e a r  incapable  attempts to  of  encompasses t h e  interests will  chapter  and  it's  organization and  political  directors.  Health  a r e l a t i o n s h i p of  on  of  is  It  virtually  partnership  [in  66 the  management o f t h e  peasant part  proposed  communities.  of  the  T h i s r e t i c e n c e and  Ministry  of  communities  can  Ministry  Health i n Hestern,  of  be  CBHC programme)  and  the a u t h o r i t y  to  invoke;  politically  transformation and  clinical  2.2.2  and  traditional  the rootedness  clinically-based  the  g r o u p s of  education i n  care  sector.  the  i s known need  to  Traditional  people  modernist  the  medicine,  governments  jobs i n the h e a l t h t o be  of  reguiring  development  health care perspective.  are f i v e  on  significant  the  health care  services.  political,  economic,  influences previously impetus and  organization the  m e n t i o n e d and  rationale  for  CBHC programmes.  specific  relationship  2.2.2.1  of  planning  and  policy  c o n c e p t u a l i z a t i o n o f CBHC a s  for rural  predicated  well  to  reflects  perceived  mark t h e  strategy  the  towards  the  A C h r o n i c l e o f P l a n n i n g and P o l i c y E v e n t s i n t h e P r o c e s s o f 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 which  also  control  communities are  Health  attributed  rural,  u n c e r t a i n t y on  t h a t t h i s system of h e a l t h  i t  with  character  and  alternative  These e v e n t s and  subseguent s t a g e s These e v e n t s dimension  provide in  clarify  of the  the as  tenuous  "community."  Improvement o f B u c a l Development o f B u r a l i n Kenya  are  professional  i n themselves  between " g o v e r n m e n t " and  P r o p o s a l f o r the S e r v i c e s and t h e Training Centres  an  events  Health Health  67 On  august  1,  collaboration  with  the  f o r t h e Improvement  and  Proposal  The  1 3  suggested  The  of  serious deficiencies i n i n the r u r a l  of  Health  in  Organization published  of Sural  Health this  blame was p l a c e d on  ministry  Health  of Sural  results  s e r v i c e s provided  however,  the  t h e World  the Development  Kenya*  of  1972,  Health Services  Training, Centres  "situational  in  analysis"  t h e s t r u c t u r e and c o n t e n t areas.  the c l i e n t  At t h e same population  time,  itself.  p r o b l e m a r e a s were d e l i n e a t e d as f o l l o w s :  a)  most rural people s t i l l service within effective homes;  have no medical reach of their  b)  most o f t h e p e o p l e do n o t know how t o make t h e most e f f e c t i v e u s e o f e i t h e r p r e v e n t i v e o r c u r a t i v e m e d i c a l s e r v i c e s , even when t h e y are a v a i l a b l e ;  c)  most o f t h e h e a l t h w o r k e r s a r e n o t u s i n g t h e 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 d e a t h , b e c a u s e i)  t h e y have n o t b e e n t r a i n e d and/or  t o do s o ;  ii)  they a r e not e f f e c t i v e l y supervised and encouraged in their practical 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 t h e a p p a r e n t  problems  interpersonal relationship [or  "health  worker"  recommendations within  the  veered  existing  were  i n t h e s o c i a l and  between " p r o v i d e r "  and  "patient"),  towards system  programmes f o r h e a l t h c a r e  rooted  the  increasing through:  and " c l i e n t " suggested  s p.e c i a l i z a t jonj  (i)  re-training  workers s t a t i o n e d i n r u r a l  areas,  68 and  _ii)  increasing the  programmes. following  It  h e a l t h know l e d g e  was recommended,  h e a l t h p r o b l e m s be  a) F a m i l y  therefore,  that  the the  addressed:  health, including family  b) Communicable  content of  planning.  diseases.  c) D i s e a s e arid conditions resulting from or provoked by inadequate environmental sanitation. d) H e a l t h p r o b l e m s r e l a t e d undernutrition.  t o m a l n u t r i t i o n and  i S  2.2.2.2 The  The D e v e l o p m e n t planning  Development  venture  Plan  began  c o m p l e t e d i n November, was  "the  objective,  the  Finance  Planning  in  the r u r a l  aspect  of  of planning  this  in  of  Permanent  areas  Kenya*s  March,  1977 a n d  poverty." Secretary of that  have t o  National  was  finally  theme o f t h e P l a n To the  achieve Ministry  development  t o the D i s t r i c t *  this of  activities  be s t r e n g t h e n e d .  e m p h a s i s would i n v o l v e  activities  Fourth  The o v e r a l l  1 6  indicated would  1979-1983  for  1978.  alleviation  and  Plan:  One  t h e de,c§ntra.l,4za.tion 7  level:  Preparation of d i s t r i c t plans i s to proceed simultaneously with preparation of the n a t i o n a l plan. This i n c r e a s e d accent on d i s t r i c t level planning r e f l e c t s our i n t e n t i o n to involve the l o c a l people i n t h e p l a n n i n g process to a greater extent than i n the past. Planning c a p a c i t y has been strengthened a t the d i s t r i c t level to facilitate local contributions to planning, acknowledging the f a c t that i t i s the people f o r whom p l a n s a r e f o r m u l a t e d who are i n the best p o s i t i o n t o know t h e i r n e e d s and p r i o r i t i e s . * 8  69 Within of  t h e 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 t h e M i n i s t r y  Finance  and  Planning,  Ministry  of  Health  personnel  engaged i n t h e f o r m u l a t i o n o f t h e h e a l t h s e c t i o n o f t h e P l a n were  encouraged  " p r o m o t i n g and particular  to  address  emphasis  given  to  s e r v i c e s t o an  and  health  promotion  discussions  inevitably  concerns.  For  and  "centred  people,  with  population."  This  e m p h a s i s on  e m p h a s i s on  disease  prevention  Nevertheless,  planning  veered  towards  i n the  for Provincial  Medical  clinical  August Officers  first  draft  chapter,  1 9  Even a f t e r  there  was  Permanent S e c r e t a r y  of the Ministry  to  lack of  criticize  preventive  the  1977  the  facilities  as w e l l as the  the submission  cause  for  of Finance  resource  meeting  of Health,  on t h e c o n s t r u c t i o n o f h e a l t h  supply."  clinical  and c u r a t i v e  16,  on m a i n t e n a n c e o f e q u i p m e n t and v e h i c l e s ,  problems o f drug  of  f r o m an  services.  example,  objective  of the  the r u r a l  to s h i f t  health care  discussion  general  protecting the health  was a r e c o m m e n d a t i o n  arranged  the  the and  allocation  of the Deputy  Planning given  to  programmes:  The b u d g e t a r y p r o v i s i o n s a r e not c o n s i s t e n t with the s t a t e d priorities. Thus c u r a t i v e health i s allocated s u b s t a n t i a l l y more resources than the £reventive health programme. Within curative health, t h e p r o p o s e d i n v e s t m e n t s 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 t h e h e a l t h s e c t i o n o f and  came  temporarily  to  press,  resolved.  these  the P l a n apparent  was f i n a l l y  approved  contradictions  The P l a n r e i t e r a t e d  were  the o b j e c t i v e s of  70 the  1972  rural  Proposal  (see  health services;  to these  2.2.2.1.)  for  the  improvement  n a m e l y , t h a t a t t e n t i o n would be  following disease  prevention  and  health  of  given  promotion  programmes: (a) (b) (c) (d) (e) (f) The  Communicable and V e c t o r - b o r n e D i s e a s e C o n t r o l . Environmental h e a l t h . Family Planning / Maternal C h i l d H e a l t h . National Health laboratories. Health Education. N u t r i t i o n , a*  Plan  these  indicated  well that  s t a t e d programme  to projects started Plan  as  stated that  participation  on  be  a self-help and  p r o m o t e d and  t o 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 birth  attendants)  health  could  services  effort  to  address  o b j e c t i v e s , a s s i s t a n c e would be  "community  will  i n an  in  be  the  basis.  In  general,  non-government encouraged.  given  , , 2  the  agencies*  2  The  extent  ( m i d w i v e s and  traditional  incorporated into  government  rural  areas  would  also  be  considered. 3 2  2.2.2.3 At  Integrated Hural the  same  formulated,  the  time  that  Senior  s e r v i c e delivery. « 2  was  Health  first  held  Nyeri,  Kenya.  was  was  D i r e c t o r of M e d i c a l  Ministry of Health,  supported  A t a s k f o r c e was  I n t e g r a t e d -Rural meeting  Plan  in  proposed  25-27,  1978  this call  (ISHS)  at the  Outspan  a  health by  created to address  S e r v i c e s Prog.ra.mme  May  being  Services  " i n t e g r a t e d " approach t o r u r a l  He  W o r l d Bank M i s s i o n .  t h e Development  Deputy  [S.D.D.M.S., R u r a l H e a l t h ) , workshop t o d i s c u s s an  H e a l t h S e r v i c e s Programme  and  the an the  Hotel,  71 The  Kenyan  health  workshop p r o p o s e d rural  health  need  t o be  National  i n order  s e r v i c e s the in  of v a r i o u s Pilot  ( s p o n s o r e d by in  that  involved  evaluating  professionals  UHO/UNICEF) 1977  approach."  In the  report  Health,  of  this  this  a  initiated call  for  "community-based  Working  i s given  Carej  Seminar,  the  as:  b)  To increase awareness/participation i n health disease prevention and simple activities.  c)  To open c h a n n e l s of communication the community and t h e established services.  community promotion, curative between health  2 6  f a r as  I can given  own  communities Health,  ascertain, by  communities  implementation,  of  the  To recognize community capacity for participating in health care and m o b i l i z a t i o n of r e s o u r c e s (manpower/material and p h y s i c a l f a c i l i t i e s ) ,  that  their  D i r e c t o r of  The  a)  credence i s fact  of  f o r a CBHC a p p r o a c h  • As  argument  would and  substantiated  the  level  whose programme was  —  the  implementing  Community-Based  —  using  •  25  in  integration in  the l o c a l  "planning,  in  integration  rationale  at  programmes."  Project  September,  to achieve  people the  participating  and  not  M i n i s t r y of could  The  Health  but  by by  f i r s t time officials i n the  health  recommendation  provided  however,  i s the  participate  management o f  areas. was  this  care to  that  to  the  planning, services in  involve  an  official  of  the  a  faculty  member  rural  Ministry of  the.  72 University  of  Nairobi  H e a l t h , F a c u l t y of  2.2.2.4  (in  the  representatives  International Alma-Ata,  Conference  U.S.S.R.,  recommendations published official  on the  Primary  September,  at  given  to  on  6-12  made  speech  of  Community  Medicine).  I n t e r n a t i o n a l Conference  Kenya's  Department  the Nyeri at  the  Primary  Health  WHO/UNICEF Health  sponsored  Care  1978)  Care  (held  at  reiterated  the  Conference..  Conference,  In  the  the  Kenyan  stated that  ... i t has become imperative that 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 t o r e a c h e a c h 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 rural areas. This means t h a t i f we are aspiring to provide e s s e n t i a l health care f o r a l l by t h e y e a r 2,000, we w i l l have to generate a d d i t i o n a l care f o r the community t h r o u g h seeking other non-conventional approaches that go beyond the traditional conventional systems. 2 7  A "two  pronged a p p r o a c h "  accomplishing clinics  and  these (b)  Already existing to  facilitate  programme. community (a) (b) (c) (d)  was  identified  objectives,  and  a community-based cadres  of h e a l t h  community They  participation  and  be  oriented  a c t as  would  means f o r  involve:  health care  through to  a  the  a catalyst  retraining  the:  d e f i n i t i o n and d e l i n e a t i o n o f "community", e s t a b l i s h m e n t o f community h e a l t h c o m m i t t e e s , o r g a n i z a t i o n o f community a c c o u n t s , and s e l e c t i o n o f Community H e a l t h W o r k e r s . 2 9  2 8  utilized  concept  in  (a)  system.  w o r k e r s c o u l d be  participation  would  as t h e  of  73 2.2.2.5 On  An I n t e g r a t e d R u r a l H e a l t h and Programme (IRH/FP) A u g u s t 7,  Ministry for  of  1979,  Planning  Document"  of  an  Programme."  (dated August  10,  Planning  Permanent S e c r e t a r y  E c o n o m i c P l a n n i n g and  the " P r e p a r a t i o n  Family  the  Family  Community  Affairs  Integrated Rural The  30  1979)  the  called  Health  preliminary  presented  of  this  and  "Working  objective:  To improve the c o v e r a g e and quality of basic health care f o r the r u r a l p o p u l a t i o n towards the overall goal of " h e a l t h f o r a l l by the year 2,000." * 3  This  document s t r e s s e d  t h a t support  would be  given  towards  t h e development of "community-based h e a l t h " a c t i v i t i e s . the  basis  different flexible  of  a  review  programmes guide  prepared.  i n Kenya,  f o r the  This guide  of  the i t  experience was  development of  would  3 2  gained  recommended  On  from that a  CBHC programmes  cover:  a)  the process of m o b i l i z i n g and stimulating communities, the advantages and disadvantages o f using s p e c i f i c l o c a l groups as focal p o i n t s (eg. churches, women's groups, co-operatives, and the administration and membership of health committees).,.;  b)  the o r g a n i z a t i o n and management of the programme by t h e community, p a r t i c u l a r l y t h e f i n a n c i a l c o n t r o l and s o u r c e s o f f i n a n c e ;  c)  the s e l e c t i o n of Community H e a l t h Workers (CHWs) and t h e r o l e s o f community and h e a l t h personnel r e s p e c t i v e l y in establishing the c r i t e r i a and the s e l e c t i o n p r o c e s s ;  d)  the f u n c t i o n s of Community H e a l t h (CHWs), their remuneration and training;  Workers their  be  74 e) t h e r o l e o f t h e h e a l t h s u p p o r t ... a n d f)  the c o - o r d i n a t i o n with, development activities  final  document,  "experimental"  dated  approach  overall  and s t i m u l a t i o n o f in other sectors  ...33  The  system i n  April  1981,  called  f o r an  t o w a r d s CBHC:  A k e y e l e m e n t o f p r i m a r y h e a l t h c a r e , o r any o t h e r health care system t h a t a t t e m p t s wide c o v e r a g e a t a relatively low c o s t , i s t h e u s e o f community h e a l t h workers (CHWs) with limited training to 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 t h e C o n c e p t u a l Formulation  The  a  particular  (CBHC).  p e r s p e c t i v e on  and  with  existing source  clinic-based  the  health  communities the  care  level  come t o  delivery  planning  active  process  on  i s repeatedly overlooked.  Integrated  Rural Health  the r e a l i z a t i o n  and F a m i l y  strategy to  systems..  that i d e a l l y  agents  care"  o f H e a l t h has  process f o r  realization  o f involvement  planning  events  health  as a s u p p l e m e n t a r y  i n this  communities a r e n e c e s s a r y , Nevertheless, t h i s  the M i n i s t r y  health care  programmes i s t h e c o n s e g u e n t  and p o l i c y  "community-based  trepidation,  of f r u s t r a t i o n  Care"  exposes the rough o u t l i n e s of  t e n years  CBHC must be c o n s i d e r e d  Health  of planning  of Health  Over t h e l a s t  gradually,  that  o f "Community-Based  preceding c h r o n i c l e  within the Ministry  Process i nthe  The CBHC rural  i n this exercise.  and d e t e r m i n a t i o n i n the p a r t  of  rural  Up t o and i n c l u d i n g Planning  Programme  75 (IRfl/FP)  deliberations,  recipient/responding  "communities"  members  in  "Communities" a r e  understood  bodies  "stimulation"  requiring  these reasons, must  be  assisted  community,"  rural  how t o t h i n k  political  the  of Health  of  bureaucratic ideas,  and  machina a n d those c i v i l  the  of the  without servants  i . e . / as  I t i s my  i s intrinsic  to the  within  process of  underlying  characteristic  Ministry of plans  (some  the country —  the  way;  perceives  themselves?  of this  and  top-down  On o c c a s i o n ,  Health  on community, a n d w i t h i t CBHC,,  significant  outside  of  position of o f f i c i a l s  objectives,  from  from  WHO).  a  structure  goals,  legitimated initiated  a l l ,  and  s t r u c t u r e o f t h e M i n i s t r y and  must be i n t e r p r e t e d on t h e b a s i s First  their  accounts,"  the conceptualization  officials  CBHC t h e y  p e r s o n s who need t o be  problem  and p r o f e s s i o n a l of  For  delineating  particular  (bureaucratic)  involuntary  committees."  the Ministry  this  any u n d e r s t a n d i n g  Ministry  and  a n d how t o o r g a n i z e  that  organizational  it.  in  process, i  them i n  community  health  t o be  "mobilization."  involve  of traditionally-minded  interpretation  the  that  communities  organizations told  of  o f community  i t then,  and  to  planning  impassive,  "defining  "organization  "establishment Why i s  i n :  the  t o be  i n an e f f o r t  are constructed  Health  reality. of  the  i s  that  are directed  and  of these eg.,  plans  are  t h e World  Bank  d e c i s i o n s a r e a c t u a l l y made d e u s ex foreknowledge o r  who w i l l  be r e q u i r e d  u n d e r s t a n d i n g of  to carry  them o u t .  76 To  reiterate  Moris  description  1  of  Third  World  bureaucracies, Downward communication i s expected; l a t e r a l communication upwards communication except sought.  facilitated i s forbidden; upon request  and and not  3 5  In  the planning  exercise  is characteristic  o f the  decisions regarding without  eliciting  areas,  already  administrative  plans,  models,  comments  Communication  through  f o r CBHC programmes,  from  made, o r t h e f a i l u r e  completely  immobilising  those  system  structure  is  t o make  who  work i n  critique)  t h w a r t e d by  delivery  rural  upwards decisions  o f any d e c i s i o n a t a l l  effective  i t  and s t r u c t u r e s f o r CBHC  (and t h e r e f o r e  the bureaucratic  therefore,  (thereby  of health  care  services). More s p e c i f i c a l l y , this  structure  regarding  rural  actors i n  this  fiat)  who  drama  vested  doctors the care  by who,  are  services,  The  usually p o l i t i c a l  positions  these  significant  The c o m b i n e d  further  alienates  t h o s e persons and communities there  i s  the authority  o f a modern, there  strategically-placed  decisions  a p p o i n t e e s (by  in  by v i r t u e o f t h e i r  delivery;  administrative  professionals.  them:  superiority  district  the  of i n d i v i d u a l s within  health care  d e c i s i o n - m a k e r s from affected  make  health care  who a r e a l s o  authority  i t i s a handful  i s  training, clinical  also  the  i n d i v i d u a l who  development i n t e r e s t s .  of  the medical  a r e convinced  approach  represents result  of  t o health  authority  The n e t  who a r e  of  tribal  the and  c a n be a n d  77 often value  i sa  concretization of  a t t r i b u t e d to  practically the  them.  reified  construction  dispensaries evaluation It  appears  rigidly for  that  embarking  amenable  densely  entangled  the  in this  to  For  with  faced  associated  with expanding  areas  problems  vehicle  according  model of h e a l t h  care  rural as  populations.  to  delivery  effectiveness reconstructed reorganization  was of  and  Similarly,  the e f f e c t i v e n e s s {as  i s so prospects CBHC)  status  of  and  identified  facilities  the e x i s t i n g  preventive  i n this and/or  light.  increasing  research  The r e s p o n s e of  of  contradictions  system o f  care  and  the expense  any a p p a r e n t  health  revision  through  In l i e u  sophistication,  by  r  allocation,  of health  usually at  this  <juo.  problems  d e l i v e r y i s r a r e l y questioned.  service,  and  model i n t o t h e r u r a l  -- the e f f e c t i v e n e s s o f  specialization,  modernisation of  that  emerging  o f r a d i c a l c h a n g e , t h e model i s f o r t i f i e d professionalism,  and  (namely,  distribution  and c o n s t r u c t i o n  to schedule  structure  net,  the  through,  scrutiny  inflexible  the c l i n i c a l  o f drug  maintenance,  r e a l i t y in,  centres,  strategies of t h i s  —  care  areas).  administrative bureaucratic  the  j u s t i f i e d and  public  urban  s u f f e r s from t h e c o n t i n u a t i o n when  is  health  populated  on a l t e r n a t i v e  example,  care  health  hospitals,  areas  (i.e.,  o b j e c t i v e s and  and s u b s e q u e n t l y i m p l e m e n t e d  of  in  Clinical  as the desirable  Government's e y e s ,  the  planned  health  care  into  the  services)  i s usually  existing  i s  one o f  strategies.  78 Concomitantly, authentic The  these  involvement of r u r a l ,  Ministry  of Health  "self-help"  activities  politically  expedient  from  any s t a n c e  power o f  open  and  t o do s o  —  would d e n i g r a t e  In  summation,  n a t i o n a l CBHC symbolic  of  clinically-based  strategy  bureaucratic  felt  below"  i s perceived further  that  i s  attempts have  ideologically  perspective,  t o be  channels.  for a  (modern) ,. a superior  constrained  by a and  unnable t o respond community-derived i n agreement  with a  i ti sorganizationally that  would p e r m i t  and i n v o l v e m e n t .  been made t o o r g a n i z e  through government-sponsored  elders  structurally  and t h e r e f o r e  participation  work  through the  where W e s t e r n  o f f u r n i s h i n g t h e ambience  o f community  and  "proposal"  to rural-based,  While i t i s  "development from  form  top-heavy  therefore,  community  (i) t r a n s l a t e d  and ( i i )  and i m m e d i a t e l y  needs.  incapable  care  organization  organizationally flexibly  —  and  with  t o imagine.  biomedicine —  health  withdraw  dialogue,  conceptualized  programme i s :  idiom  h e a l t h care  the  i ti s  the authority  principle,  personnel  h e a l t h workers i s d i f f i c u l t  since  and c o - d e t e r m i n a t i o n  In  and  recognize the  but i n r e a l i t y ,  communication,  of Health  full  communities.  r u r a l communities —  To do s o  productive  the  e n c o u r a g e and  i t s own p o s i t i o n .  between M i n i s t r y and  may  of  override  peasant  of negotiation  r u r a l communities. and  strategies  such a system  this  And y e t , o f CBHC  79 2.3  THE SOCIAL ORGANIZATION OF AH "EXPERIMENTAL" COMMUNITY-BASED HEALTH CARE PROGRAMME ... as experience elsewhere demonstrates, i t is very difficult to e s t a b l i s h adequate linicaqes between t h e formal health s e r v i c e s and community health 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 Health's lack of experience in this area. 3 6  2.3.1  F o r c i n g t h e I s s u e o f Community-Based H e a l t h 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  previous  indicates,  it  Ministry  took  of  By  quite  Health  "community-based specific  record  Republic  3 7  of  care"  of  the of  on  r e p o r t s of for:  the  other  existing  a  health  officials  (biomedical)  Even  mere  15-3035 o f  one  c o n s t r u c t i o n of health  c o n s i d e r a t i o n of  rural  health  sub-centres, an  "integration"  countries  Health  care  rate  the the  statistical population, response of  by  their  of  s e r v i c e s was expansion namely,  dispensaries; of  in  resisted  the  a  T h e i r r e a c t i o n to  facilities — and  already  the  3 9  orientation.  i n c r e a s i n g the  programme.  characteristic  u n d e r - u t i l i z a t i o n of health (i)  in  though  services,  was  resulted  adjacent  hand,  by of  o r CBHC was  Ministry of  s i m i l a r plans.  Health  professional  (PHC)  events  topic  for a national  The  3 8  the  eventually  plans  Sudan.  policy  discussions  around  programme i n t h e  indicated that  utilized  centres,  the  Kenya,  formulation  plan  and  and  time before  health care  implemented  of T a n z a n i a  Ministry  some  r e c o m m e n d a t i o n s and  recognized,  planning  officials  health  t h i s time primary  studies  of  Care:  services  4 0  ;  tq and  health £ii)  approach;  a 4 1  80 and  ( i i i ) the  existing  c a d r e s of  animateurs."* Field  organization  of a r e - t r a i n i n g  health  workers  Additionally,  2  Educators  (FHFEs)  the  was  to act  new  the  opposition  and  the  "formal"  "community"  —  or  sectors.  Furthermore,  sustained  by  and  " n a t i o n " and  and  "urban !  communities,  The  f o r example,  traditional  medicine,  traditional  birth  herbalists,  diviners,  and  caused  sorcery.  From t h e  physicians, activity  must  effective, also  perspective world  give  way  to  t o be  officials  to c r e a t e The  of the  "professional" links  purpose of  documented  between  doing (i)  so,  to  however,  a purely  of  attendants by  (TBAs) ,  witchcraft  and  nation  i s to  flesh-out  I explore  and  (Kenyan)  mis-directed of  at l a r g e .  an  then  communities. review the  the  actual,  organizational  (see F i g u r e the  It  therefore,  t o i m a g i n e and  rural  s t r u c t u r e o f a n a t i o n a l CBHC programme Before  experience  T h i s development i s  Health  with  this section  attempts  and  change i n p e r s p e c t i v e ,  M i n i s t r y of  of  "rural,"  the modernizing i n f l u e n c e medicine. .  and  evokes images of  misguided  b e n e f i c i a l f o r the  require a dramatic  health  language  of Western^trained  of  clinically-based  perceived  would for  this  diseases  these  "government"  i n the  "community" c o m p a r i s o n s . ,  peasant  of  concretized  and  1  MSSiife  "informal"  officials  "modern,"  one  between  for  "community  Familx  Each  4 3  d i f f e r e n c e s are  M i n i s t r y of H e a l t h  "traditional"  rural,  these  as  cadre of  created.  approaches accentuates  programme  5).  transitional  c l i n i c - b a s e d approach  and  phase  (ii)  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 t h e 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  M i n i s t r y - o f Health - Headquarters D i r e c t o r o f Medical S e r v i c e s  . Central 'Central"  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 [Also D i r e c t o r of National Family Welfare C e n t r e and R u r a l H e a l t h Development P r o j e c t ] R e s o u r c e A d v i s o r y Group —[ A f r i c a n M e d i c a l and R e s e a r c h F o u n d a t i o n (AMREF), United Nations International 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]  R u r a l 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 Medical O f f i c e r o f Health  D i s t r i c t Medical O f f i c e r o f Health D i s t r i c t R u r a l H e a l t h Management Team [Community-Based H e a l t h C a r e 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 , Public Health Technicians, Health Educators]  Community H e a l t h Committee COMMUNITY HEALTH WORKERS  Provincial "Intermediate" 1 District [Divided into: Divisions, L o c a t i o n s , and Sub-locations] "Intermediate" Rural "Peripheral"  82 "experimental"  approach  community-based taken  by  programmes.  of its  areas.  Health  The f o l l o w i n g programme  position  2.3.1.1  reiterates,  regarding  six  Sural  after  the i n i t i a l  the  were  problem o f  care s e r v i c e s i n the statements firmness  by M i n i s t r y  and t e n a c i t y , model.  results  were  Report.  integration  plans f o r the c o n s t r u c t i o n  Training  Centres  were  e f f e c t i v e n e s s was o r g a n i z e d  H e a l t h Development P r o j e c t  S.ec_uest  which  t h e v i r t u e s o f the c l i n i c a l  Health  evaluation of their  The  with  and  On " I n t e g r a t i o n "  Seven y e a r s of  to r e c t i f y  of preventive health  officials  clinic-based  These were t h e s t e p s  the M i n i s t r y o f Health  under-utilization rural  combining  made,  an  by t h e R u r a l  (RHDP) of t h e M i n i s t r y o f H e a l t h .  presented  in  the  A E E r a i s a l and  Project  T h i s r e p o r t e m p h a s i z e d t h e n e c e s s i t y f o r an  of s e r v i c e s p r o v i d e d  in rural  areas:  when we t a l k o f " i n t e g r a t i o n " we r e f e r b o t h t o t h e creation of a strong and tangible, inter-relationship, both functionally and ideologically, between t h e various divisions within the M i n i s t r y of Health, as well 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 p r o b l e m 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 policies within the c o n t e x t of r u r a l development.** The  Ministry  functional specialized  of  Health  problems approach  resulting  from  the  operational  a fragmented  to health care delivery.  c o o r d i n a t e a merging o f health  recognized  curative,  promotion a c t i v i t i e s  and  and h i g h l y  &n a t t e m p t t q  disease preventive,  was p e r c e i v e d t o be  and  of b e n e f i t  83 to  t h e consumer  report plan  on  of h e a l t h  "Kenya's R u r a l  for i n t e g r a t i o n of  care  Health  services. Services"  A  subsequent  re-emphasized  the  services:  In the new MCH/FP (Maternal C h i l d Health/Family Planning) programme care arrangements, the services for m o t h e r s and children will be on a daily basis and integrated. , 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 , child welfare, family planning and health education s e r v i c e s , i s expected to ensure more effective health care coverage for families i n general and for mothers and children in particular. 4 5  This quotation  e v o k e s an  is  modern, and  attractive,  to  the f a c t  that  understand the  2.3.1.2 At  the  On  they  time  the  that  M i n i s t r y of of r u r a l  fashion, health  reference  may  not  efforts  Health health  were  that  is  given  perceive same  or  way.  w o r k e r s . ...  The  educated  and  Planning) informed  in their  own  the  health  would be members  officials  care  made  to  (eg.,  better  were.  services in re-train.  message f o r  that h e a l t h i n t e r v e n t i o n tasks  Health/Family  participate  services  these s e r v i c e s i n the  operation  cadres of  w o r k e r s was Child  No  populations  b e n e f i t s of  same  integrated  existing  rural  efficient.  health  "Community P a r t i c i p a t i o n "  reorganizing an  image of r u r a l  health  Maternal  received i f  of communities  care:  The r o l e o f community p a r t i c i p a t i o n as a partner in the g e n e r a l effort of improving the health s t a t u s o f f a m i l i e s has n o t been f u l l y a p p r e c i a t e d by the majority of our h e a l t h workers in our institutions. T h i s i s one programme whose s u c c e s s v e r y much d e p e n d s 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 a r e geared towards improvement of the health of  to  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 n e c e s s a r y t o i n c u l c a t e i n t o t h e minds o f o u r h e a l t h w o r k e r s t h e need f o r them t o a c t i v e l y s e e k community p a r t i c i p a t i o n f o r their health c a r e . 4 6  This  q u o t a t i o n by  Services Health,  the  Senior  [S.D.D.M.S., calls  for a  Deputy  Eural  Health)  in  more c o m m u n i c a t i v e ,  sophisticated health  care  [employed  Government)  by  D i r e c t o r of  the  worker.  The  p r o f e s s i o n a l i n matters  care services.  He  lives The and  of r u r a l  implication  of t h i s  seemingly statement  community" members  subsequently  need  participation;" services.  i.e.,  members  appreciated,  ascribed  are to  w h i l e an  community be  a l s o expected  peasants  the  to  health  care  d i s c u s s e d by  of  and  worker to  to  be  health in  the  u l t i m a t e good.  and  uninformed  educated the  in  clinical  d i a l o g u e of i d e a s  these  comments  are  between  workers  would  suggests  the h e a l t h c a r e worker. , behaviour  and  "community  available  Government h e a l t h c a r e nature  of  i s that "individual family  to u t i l i z e  superiority  regarding  relating  for their  e x c h a n g e and  and  care  to intervene  impassive be  influential,  instructed  k n o w l e d g e a b l e and  i s  the M i n i s t r y  health  is  Medical  an  Directives  imposed  and  the Government h e a l t h c a r e worker i n the  not  client  population.  2.3.1.3 The  The " F a m i l y Programme Family  c r e a t e d by  the  Health  Health F i e l d Field  Ministry  Educator"  Educator  (FHFE)  o f H e a l t h t o form  (FHFE) programme a "link"  was  between  85 rural  health f a c i l i t i e s  these  services.  deployed there  be  These workers [a  Health)  services.  prevention,  (FHFEs) five  women i n t h e  Child  - - t o be health  population  by t h e  —  educators  f o r these of child  t h a t b y 1983 Government.  MaSignal Family  rural  as t h e i r  Health  bearing age  to  use the (HCH/FP)  professional  and m o t i v a t o r s  Family  Welfare  Planning  and f a m i l y  4 8  M i n i s t r y of  areas  Health / Family  promotion,  a r e women  457 F H F E s  Health S e r v i c e s ,  They a r e i n t e n d e d  indicates  1978 t h e r e were  by t h e  of Rural  Maternal  i n need o f  employed  are trained  encourage  communities  and i f i s e s t i m a t e d  4 7  1,334 FHFEs  division  to  available  target  By t h e end of  t o the P r o v i n c e s  will  Centre  and t h e r u r a l  in  title  disease  planning. Field  The  Educators  and c h i l d r e n  under  years of age.  P a r t and p a r c e l o f t h e FHFE's j o b d e s c r i p t i o n not  only at  the c l i n i c ,  The  FHFE i s e x p e c t e d t o  but p r i m a r i l y  i s t o work,  i n the community.  4 9  generate public support f o r the Maternal Child Health and F a m i l y P l a n n i n g programme, and t o f o l l o w - u p and make r e a s s u r a n c e v i s i t s t o mothers and a c c e p t o r s o f F a m i l y P l a n n i n g m e t h o d s . 5 0  Most o f t h e s e a c t i v i t i e s are  to  be c a r r i e d  But  i nfact,  i n v o l v i n g education  out i n  a s one r e p o r t  home-visiting i n  and m o t i v a t i o n t h e community.  suggests:  t h e F i e l d E d u c a t o r s may s p e n d t o o much t i m e i n t h e c l i n i c s and t o o l i t t l e time i n t h e communities, thus l i m i t i n g t h e i r c o n t a c t s w i t h t h o s e women who p r o b a b l y would n o t a t t e n d t h e c l i n i c s f o r any k i n d of service without additional i n f o r m a t i o n and motivation. 5 1  86 An  evaluation  Educators of the  remaining  i s spent  time  Furthermore,  is  while  (FHFE)  education  work  (FHFEs) c o n f i r m e d  time  Educator  of the  and  by  load these  the  spent  of Family suspicions.  FHFEs i n t h e  traveiling  at the c l i n i c , is  involved  health promotion.  Health Only  Field a  third  community,  or a t  the  the Family  in  everything  She  spends  the  clinic.  Health but  S 2  Field health  time  taking blood pressure, weighing mothers and children, g i v i n g immunizations, giving cards to c l i e n t s , g i v i n g out medicine, taking temperature, sterilizing equipment, examining clients, and c l e a n i n g the c l i n i c . 5  A year a f t e r still  this  3  e v a l u a t i o n r e p o r t was  t h e hope o f H i u i s t r y  of Health  published,  officials  i t  was  that  the s t y l e of t r a i n i n g , r e c r u i t m e n t and d e p l o y m e n t o f the FHFE ( F a m i l y H e a l t h F i e l d Educator) will p r o v i d e an i n d i v i d u a l who i s b o t h a c c e p t a b l e and accessible to the community for purposes of enlisting total community participation in a c t i v i t i e s r e l a t e d to family h e a l t h . * 5  2.3.2 The  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 C a r e " Programme apparent  b u r e a u c r a t i c c o n s t r a i n t s within the M i n i s t r y  of Health  due  make t h i s  interpretation:  "problem"  to i t s  of  rural  under-utilization  of  simply  and  re-^worked  strategies. s e r v i c e s so  clinical  orientation  in i t s  attempt  health  permitted to  re-organized  E m p h a s i s was as t o i n c r e a s e  placed the  address  services  preventive services) ,  the  the  Ministry  "management"  integration  attractiveness  to  (namely,.  the  existing on  me  of  of services  87; kt  offered. Field  Educator  positive Child  t h e same t i m e ,  (FHFE) was c r e a t e d  response from  Health  experience  Planning  more c o m f o r t a b l y than i n  p r o m o t i n g community meaning  re-organized  health  to  elicited. within the  Ministry  words, of  services.  The  that  implicit that  a  care  "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  administrators programmes Ministry Ministry  —  of  and  Health.  of Health  —  of  policy  i s  services  the axiomatic  bent o f  biomedical p r i n c i p l e s ,  and e x p r e s s e s  2.3.2.1  The S h i f t i n g  Paradigm  by Western,  the p r o g r e s s i v e  officials.  the  clinically-based  this tactic i s validated  of Ministry  CBHC  p r i n c i p l e of  systems o f h e a l t h care;  modernist o r i e n t a t i o n  Ministry  self-directed  t o promote  by  i n t h e meaning  the epistemological  Clearly,  i s  officials  between t h e v i e w o f  proponents  highlights  favourable  participation"  community  participation"  i n these  to administrative  Health,  Indeed,  services  efficient u t i l i z a t i o n of clinic-based  "community  "educator"  i n t h e community.  health  health  clinically-based  means an  of  these  a c t i v i t i e s of  ventures i s  clinically-based In other  and  (MCH/FP)  participation"  care  t o Maternal  engaged i n  participation  Health,  to "hopefully" stimulate a  however,  t h e proposed  o f "community  of Family  populations  w i t h FHFEs i n d i c a t e d ,  activities  response  rural  and Family  w o r k e r s were  the  the p o s i t i o n  and  88 With  the  impossible  realization  to  sustain  (clinic-based) gradually  compelled  an  index  allocation recognize  by  in  the the  &2aSS^ zone,  divided  r a i s e d the to  the  the issue  Health of  was  "community  to the  Government's  needs and  came  such  t h i s f a c t o r , the  .Rural  zone, the  Health  Initial involvement: conditions Republic  Service  marginal zone, the  zone.  s 5  This  mapping  to  priorities  r u r a l communities.  clarify  of  Delivery. hot/humid procedure  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 conditions.  i t was  recognized  cultural  considerations.  Migue and  their  article  excellent  notion  rough o u t l i n e s of  semi-arid a  of  curative  i t gradually  nature of  into four  of  economically  differences in ecological  To  environmental  and  the  of  highland  Subsequently, social  services,  members of  r u r a l areas.  and  Ministry  r e - i n t e r p r e t the  care  adumbrate  the  the  sui generis the  be  trends emphasizing  response/utilization  recognition  K e n y a was  would  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 "  health  the  attempts to was  of  of  generated  to  Rather  i t  current  services,  involvement." as  that  on  that  environment  differences were  Ndungu i d e n t i f y t h e s e "Rural  Health  in  necessary problems i n  Management  Kenyan E x p e r i e n c e : " Socially and culturally, the people exhibit different characteristics and i t will be unrealistic to b e l i e v e that one h e a l t h service delivery system can adapt to these diverse conditions. I t i s therefore necessary to develop a service 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 plans for i n v o l v i n g the community more e x p l i c i t l y in health care, must r e c o g n i z e particularly social s t r u c t u r e s and values. s 6  the  -  the  89 With t h e r e a l i z a t i o n and of  that  variation i n social,  environmental c o n d i t i o n s i s the rural  a r e a s s e r v i c e d by  problem remained the  Western Kenya  critical  work w i t h  and i m p l e m e n t a t i o n  of the National P i l o t  She c a l l s  section,  in a  The  Kenyan  scheme  of  for  information  CBHC i n  Health  The Health central  as  5 7  Health  Care  as b e i n g  the  study  c a n be i n i t i a t e d a n d In  5 8  the  Ministry  a national  of  CBHC  construct  following Health's  programme this  (sponsored  by  from  i s  scheme i s  reports of the P i l o t  w e l l as  o f how  Project  the Ministry  Ministry of  of  Health  documents on t h e s u b j e c t .  Proposed latest  Central  4ppraisal  and D i s t r i c t Beport  and Family, P l a n n i n g and d i s t r i c t at  Community-Based  Health  Development U n i t  s 9  of  Programme  Level  the c e n t r a l  Organization  the Integrated (IRH/FP) p r o p o u n d s  l e v e l organization  CBHC programme.  This  the  used t o  Kenya  and UNICEF)  proposal  2.3.2.2  Western  care  setting.  t a k e n from t h e few p r e l i m i n a r y on  The D i r e c t o r  f o r the systematic  description  organizational given.  the  process  the  situationi n  o f CBHC.  this  community p a r t i c i p a t i o n i n h e a l t h established  this  P r o j e c t i n Community-Based  identifies  issue.  characteristic  the Ministry of Health,  a s t o how t o  organization  in  a prevailing  cultural,  level,  f o r the there  C a r e Development U n i t  Rural this  national  i s planned a  (see F i g u r e 5 ) .  would  help t o f o r m u l a t e p o l i c y , promote community-based h e a l t h c a r e schemes, r e v i e w and a p p r o v e p r o p o s a l s f o r schemes t o be f u n d e d from p r o j e c t f u n d s , s e t  90 guidelines f o r CHW (Community Health Worker) stipends, train s t a f f of d i s t r i c t Rural Health Management Teams i n community-based health care, and m o n i t o r and e v a l u a t e s c h e m e s . 6 0  This  U n i t would be s u p p o r t e d  with t e c h n i c a l  Be,source A d v i s o r y G r o u p  composed  Department  Health  UNICEF  o f Community  (United Nations  Fund),  and  AMREF  a s s i s t a n c e by a  o f r e p r e s e n t a t i v e s from  (the U n i v e r s i t y o f N a i r o b i ) ,  International Children's  (the  the  African  Medical  Emergency  and  Research  Foundation) . » 6  At t h e d i s t r i c t District  Development  district schemes. the  level,  who  selecting,  paying,  (CHWs).  oversee  t h e work  the  them  be  Furthermore, of the  National  level  Pilot  brought together Community  Worker,  (the  Family  Development and H e a l t h  communities i n  Health  Unit.  The  health care  Health F i e l d Assistant,  Educators.  6 3  would and  funding  to  composition  C a r e Team" i n Health  personnel: Public  Educators  Care a  Health  (FHFEs),  an A g r i c u l t u r a l Once a g a i n ,  Health  Team  for  Health  Leader),  of  Committees  i n Community-Bashed  Team  (see  responsibility  District  "Community-Based  the CBHC  Committees  of p r o p o s a l s  the f o l l o w i n g  with  t h e i r Community  the  Development  Project  Nurse  Technicians,  the  Community  i n the s u b m i t t i n g  the D i s t r i c t  Health  given  of the  i n promoting  to a s s i s t  and s u p e r v i s i n g  Ministry of Health's  Community  Tea.m  Community  would  Workers  of  Management  of  Sub-Committee  would work c l o s e l y  T h e i r f u n c t i o n would be  6 2  2.3.2.3.)  the  Committee  Rural Health  establishment  assist  the Health  a  Extension  their function  91 was t o a s s i s t support  communities i n  the establishment  structures.  This  complex  administrative  organization  a c t i v i t i e s a t t h e C e n t r a l and D i s t r i c t as  t h e necessary "supportive  the  community.  to  this  for  infrastructure  the function  words,  CBHC.  care  two g e n e r a l  the  6 4  outside of  functions  attributed  as  i t affects  o f CBHC a c t i v i t i e s .  level  teams a c t  "community  activities  and a s s i s t  support  the  Firstly,, 6 5  In,  as f a c i l i t a t o r s  T h e s e teams a r e t h e " c o m m u n i c a t i o n of  CBHC  of " p a r t i c i p a t o r y m a c h i n e r y . "  district  promotion  of  l e v e l s i s referred to  central machinery"  and i m p l e m e n t a t i o n  fulfills  other  There a r e  health  initiation it  o f community  tool"  structures"  6 6  i n the  for  CBHC  i n the;  i)  t h e p r o c e s s o f d e f i n i n g and d e l i n e a t i n g t h e u n i t o f community — the functional base for c o m m u n i t y - p a r t i c i p a t o r y activities.„  ii)  the establishment  o f Community H e a l t h  iii)  the establishment  o f Community  iv)  t h e s e l e c t i o n o f Community H e a l t h  The  second  infrastructure programme  function —  on CBHC  of  as  i t  —  i s that  the  affects  Accounts., Workers.  health a  Committees.  care  national  i t acts  system  Government  as t h e  necessary  s u p p o r t s t r u c t u r e f o r m e d i c a l problems too d i f f i c u l t Community  Health  satisfies  a fundamental  CBHC;  i . e . ,that  clinical  Worker  (CHW).  an e f f e c t i v e  (curative)  This important  principle in  support  6 7  f o r the function  the organization  of  CBHC programme r e g u i r e s t h e  of  the  health care  service  92 infrastructure. (CHW)  For  i s confronted  his/her  expertise,  patient  to  the  e x a m p l e , when a Community  the  with the  next  CHW  level  dispensary, health  again,  that  6 8  implement:  2.3.2.3 The  as  and  in  the  health  or  Ministry  b e i n g an  National  be  "informal The  view  trends  migration  of  persons to  the  the  the  the  Level CBHC  delineating activities  Director  of  Health  Care  "village," is  are  to and  that  the  actually  the  lingaass*  clans, and have  the  structures  Director  however,  towards  schemes, l a n d  as an  and  to  care."  proposed  structures,"  composed o f  bonds,  by  groupings  health  the  formal structures"  affected  mobility,  of  pronged  "Community"  As  Once  proposes  Community-Based  formal  organizations  These o r g a n i z a t i o n a l  of  "two  a number o f o r g a n i z a t i o n a l  "informal  resettlement  a t the  documents on  in  are  traditional  a  "community-participatory"  Project  69  of  the  (i.e. ,  Hospital).  problem of d e f i n i n g  suggests, there  "community."  system  Health  important consideration.  considered:  referring  care  "community-based  of Health  Pilot  so-called  of  Worker  t h a t i s beyond of  District  importance  Proposed O r g a n i z a t i o n  f u n c t i o n a l base f o r  level  recourse  Ministry  programme i d e n t i f i e s t h e the  the  the  the  "clinics"  has  centres,  t h i s confirms  approach"  a medical problem  Health  been s e r i o u s l y  modernization.  With  the  u r b a n a r e a s f o r work, a l o n g  with  purchases,  and  importance  of  organizational  an  increase  clan  p r i n c i p l e has  and  in  the  lineage  diminished.  93 For  these  reasons,  she suggested  that these  traditional  s t r u c t u r e s may n o t be s u i t a b l e a s a f u n c t i o n a l b a s e f o r CBHC activities. For s i m i l a r of " v i l l a g e " term  reasons,  this Director believes that  i s an i n a d e g u a t e  "village"  itself  "village" easily composed usually of  i s identified  identifiable  a smaller  area  instances,  a cluster  (perhaps  of  within  however,  a  h o m e s t e a d s i n an  along  a  persons. * 7  u n i t w i t h i n the l a r g e r ,  terms o f t h e e x p e r i e n c e appears  organization delimited  ridge)  and  A "village" i s  geographical  unit  of  area.  most  ( f o r example  government. Western  by  Project,  the  unit  f o r the  functions,  preferred 7 2  into  and  organizes  i s  geographically  t o be s o by r e s i d e n t s i n administrative  l o c a t i o n s and s u b - I o c a t i o n s )  a leader  disputes  It  i t follows  formally  leader  Kenya i s t h e l i g u r u  activities.  Each area  cases,  The community  p e r s o n who s e t t l e s  experience  be  Pilot  CBHC a c t i v i t i e s .  In  i s headed  public  to  of the N a t i o n a l  and i n f o r m a l l y r e c o g n i z e d  boundaries  in  with  o f households o f r e l a t e d  "community"  and  I n some  7 0  groupings  The  "community." In  the  f u n c t i o n a l b a s e f o r CBHC.  i s associated "with  religious denominations."  the unit  in  recognized  i n the P i l o t  ( p i . maguru). the area,  7 3  by  the  Project  area  7 4  He  carries  people f o r " s e l f - h e l p "  i s the  out basic and o t h e r  7 5  i n the country "community"  i s different,  f o r varying  however,  participatory  a n d may reasons,:  94 It  may  at  the  involve  who  same s p r i n g ,  leader. that  persons  go t o t h e same m a r k e t ,  o r who  Whatever t h e  reason,  makes them p a r t i c i p a n t  Community,  therefore,  membership w i t h suggests that  benefit  the  For  mobilized  "target  a specific  could  t o engage i n  outgrowth  These  7 8  units  whose  7 6  will  CBHC programmes, the D i s t r i c t  groups  within  Community  Health  ya  the  etc.  protection,  mentioned  the  community  —  Each  improving  of  be  an  groups  and  would  member  be  would  on b e h a l f  of  sanitation,  outbreaks, immunizations, members  which  be o r g a n i z e d  w i t h i n the Committee  availability, cholera Furthermore,  would  development  a p p r o x i m a t e l y t e n members.  spring  As  within  women's g r o u p s ,  function  wanawake),  Committees c o u l d  of existing  teams  community.  i n t h e community  structure  the  cooperatives,  maendeleo  groups  level  the  be c h u r c h g r o u p s ,  Kiswahili,  or extension  community:  food  of  repqrt  a c t i v i t i e s that  Community H e a l t h C o m m i t t e e s  have a s p e c i f i c  on.  (in  as c h u r c h g r o u p s ,  composed o f  the  may  7 7  as t h e f a c i l i t a t i n g  CBHC.  such  One  a c t as a s p r i n g b o a r d f o r t h e programme.  act  for  social  o r other development  previously, to  area.  100-400 h o u s e h o l d  of implementing  groups"  groups  schools,  community.  whole.  pre-formed  women's  t h e same what i t i s  in a certain  M i n i s t r y o f H e a l t h recommends t h a t  These  share  water  i s an e x p e r i e n c e o f b e l o n g i n g and  persons i n  the purpose  identify  and  t h e p e o p l e know  members  i t constitutes  members c a n be  recognize  draw  the Community  and  so  Health  95 Committee and  would be r e s p o n s i b l e  s u p e r v i s i o n o f Community H e a l t h Workers  2.3.2.4  The Community  The  Community  Community the  f o r the s e l e c t i o n ,  Health  H e a l t h Committee  communities they  Educator  H e a l t h Workers  (FHFE)  Worker i st o  serve.  (CHWs).  (CHWs)  (CHW)  selected  be a p a r t - t i m e  Unlike t h e Family  who i s a f u l l - t i m e  Worker  required are  (CHW)  i s similarly  restrictions  to  be  criteria  women  Project  f o r the s e l e c t i o n i s t h a t they thirty  person  good s p i r i t . "  a  t h e Community H e a l t h  years  Worker  though  i n CBHC, of  or  gealth  Ejeld,  t h e Community but  would  be:  Community  a r e no  Health  Workers.  Health  i n the  above with  there  f o r example,  (CHW) a r e d e f i n e d  the  Workers  l o c a l language,.  children,  The t a s k s t o  7 9  employee o f  The m a j o r i t y o f CHWs  Community  be " l i t e r a t e  mature l a d i e s with  even  a g a i n s t men becoming  In t h e n a t i o n a l P i l o t  (CHWs)  trained  t o work o u t o f h i s / h e r home.  expected  by t h e  employee o f t h e M i n i s t r y  o f H e a l t h a n d p r o n e t o work o u t o f t h e c l i n i c > Health  support,,  and a  be p e r f o r m e d by as f o l l o w s :  Although t h e d u t i e s o f CHWs would depend t o some e x t e n t on t h e l o c a l h e a l t h s i t u a t i o n , a l l would b e expected t o undertake the treatment o f common ailments, including oral rehydration, health education, family planning c o u n s e l l i n g , motivation and c l i e n t f o l l o w - u p , t h e a d m i n i s t r a t i o n o f s i m p l e vaccines, and t o t a k e p a r t i n c a m p a i g n s a g a i n s t communicable d i s e a s e s . 8 0  fiemuneration  for  H e a l t h Worker  £CHW)  Other than  that,  the services i sleft  provided  by t h e  t o t h e communities  the M i n i s t r y  of Health  has  Community themselves.  o f f e r e d only  96 general  guidelines.  ( s p o n s o r e d by  the  recommended  that  community.,  To  household 10/=  In  the  Ministry  a Community begin  i n the  Pilot  of Health  and  Account  the  community  (shillings). .  National  an  Health  1/=  Horkers  ONICEF),  i t is  established  i n each  i s expected  to  Subsequent d e p o s i t s  s e r v i c e from  a d u l t and  i n CBHC  remunerative  Community A c c o u n t e a c h t i m e t h a t of c u r a t i v e  be  Project  their  [shilling)  (CHHs) a r e  paid  process,  each  make a d e p o s i t are  made  into  CHB  —  3/=  (shillings)  from a  child.  The  50/=  (shillings)  8 1  out  of  work a p p r o x i m a t e l y  days per  preceding  "organization"  discussion  i n the  CBHC programme.  The  this  section,  proposed Health  on  moments i d e n t i f i e d  I discuss  some o f  and  the  construction  moment a  i n the  process  management.  the  of  national  implications by  They  Health  the  constructing  organization,  organizational  In  of  the  Ministry  of  f o r CBHC.  With t h e needed  process of  three  conceptualization,  focused  this,  communities.  D i s c u s s i o n o f t h e M i n i s t r y o f Health*,s O r g a n i z a t i o n a l Scheme f o r Community-Based Cage "(CBHC)"  The  are  week i n t h e i r  from  Community  month f o r s e r v i c e s r e n d e r e d .  2.3.3  the  a p e r s o n r e c e i v e s some form  Community A c c o u n t o n c e a three  of  in  suggestion the  ( " c l i n i c s and noticeable  that  delivery  a "two  of  rural  community-based  health  shift i n rural  health care  pronged  approach"  health  care  services  care"), there  emerged a  strategy.  was  Initially*.  97 the  Ministry  of  Health  invoked  through a r e - o r g a n i z a t i o n  "community  participation"  of the r u r a l h e a l t h  care  service  infrastructure.  I t planned f o rthe " i n t e g r a t i o n " of health  care  a "re-orientation"  services,  workers,  and t h e c r e a t i o n  (FHFEs).  These  expected health of  care services  from  infrastructure  "participatory  re-organization  to  a  machinery"  in  programmes. the  within  influence (where i t  the  In actual  Ministry  of  has complete  a  method  of  of  rural  meaning,  of  Health.  t o emphasize the context  the Ministry the of  t h e community.  fact,  and  of  Health  health  care  the  the  community.  creation  t o work  development  the organizational  proposes  service  f o r CBHC  control)  possibility  of  alongside of  extends i t s  to that  that  base  of r u r a l  the M i n i s t r y of  H e a l t h i s n o t y e t aware o f t h e l o n g - t e r m i m p l i c a t i o n s Nevertheless,  CBHC  structure  from t h e e n v i r o n s o f the c l i n i c  own p o l i c i e s a n d p r o c e d u r e s .  of  On t h e s u r f a c e , i t  i s willing  planning  I t may be a  the  planned f o r t h e o r g a n i z a t i o n o f to f a c i l i t a t e  Health  and a u t h o r i t y  communities.  the Ministry  health  Educators  the a c t u a l  re-organization  as i f the M i n i s t r y  communities  by  a  support structures  —  p a r t i c i p a t i o n " within employed  as  utilization  p o l i c y began  Ministry o f Health o f f i c i a l s  appears  interpreted  community  of Health  for  Health F i e l d  effective  by t h e  the strategy  shifted  were  the  f o r "community  CBHC,  Family  p a r t i c i p a t i o n " within  When M i n i s t r y need  changes  to increase  "community  of  programme  of i t s  i tcontinues t o  98 o p e r a t e as and  i f health  delivered  t o the  (through d i a l o g u e For  example,  created on  the  they their  The  part of  and  areas  has  for  Health  procedure through  the  respective  that  activities  are  than  provided  constructed  community the  members.  creation  and  Committees w i t h i n  each  which t h e s e c o m m i t t e e s  are  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  community  organizations  with  called  autonomous  services  rather  discussion)  o f Community  b e l i e s any  are  ideas  rural  and i t  establishment community.  care  members t h e m s e l v e s . are  by  d i r e c t e d and  the  District  Instead,  supervised  in  level  Management  serious  long-term  teams. This  organizational  problems  f o r the  implementation  national scale. construction health care will of  scheme  I f the  of  Ministry  "communities"  process,  as  community  n e v e r assume t h e  r o l e of  poses of of  CBHC  programmes on  Health  a  persists in i t s  reelpients/clients members i n t h e  in  rural  a c t i v e agents i n the  the  areas  creation  CBHC. Initially,  Ministry  the  implementation problem  of Health  "community  was  of  question  stated,  Health  of  legitimacy  to f a c i l i t a t e  participation."  meaning o f "community Ministry  how  of  how  But  as  was  p a r t i c i p a t i o n " that  documents to  convince  turns  that  the  the  process  of  mentioned,  the  problem i n t o  community  Ministry  the  by  i s c o m m u n i c a t e d in.  this  Government h e a l t h c a r e  therefore,  formulated  members  methods. of H e a l t h  It  of  the the  can  be  fails  to  99 appreciate  traditional  organizational their  health  ability  managers  politically efforts  in  the  rural  advance a c l i n i c a l ,  their —  knowledge  of the  Ministry i n while  Health  upper  find  i t  f o r Harambee  principle  programmes  — t h e i r  which  by  individual  a s p h y s i c i a n s c a u s e s them t o a c t u a l l y  curative-based In t h i s  stronger  model f o r t h e d e l i v e r y o f  latter  Government  this  particular  i s subsequently  bureaucratic  constrains  programmed i n a c e r t a i n the  organization of  and  reproduce  opposition  reified  of the way  emphasis,  f o c u s on  they  link  "development  and  of  health  i d e a s and p r i n c i p l e s  care s t r a t e g i e s  Once  format),  against a l l  o f CBHC i s j u s t  critique  health care  system,  transform  t h i s system  o f knowledge t o s e r v e the  the  i n s t e a d o f a p p r o p r i a t i n g the  o f CBHC a s a r e l e v a n t  respecting  by  seems t o expand  existing  than  care  Health.  i n a biomedical  The a l t e r n a t i v e  tendency:  health  reproduced  the M i n i s t r y of Health  existing  of t h i s  idiom  Ministry of  .i.e.,  and r e s i s t a n c e .  example  Bather  managing  r e f l e c t s and  support  a  the  modernisation."  Furthermore,  one  areas  services.  with t h e  through  this  of  and  in  Ironically,  Ministry  t o voice  professional interests  arms  the  s a n c t i o n s CBHC  health care  members  again,  tradition.  within  expedient  definition  once  community  e p i s t e m o l o g i c a l rootedness  Western, b i o m e d i c a l  level  of  o f community  care needs.  reveals the the  experiences  i t seems t o  autonomy  of the  wash o v e r  and  i t s own n e e d s .  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 forms  of  CBHC  sustained  by  —  with  these  transformed these  CHHs  no  t o l e r a t e d between  the  community  the  their  (periphery)..  the  own  generics  respective of  there  and  government  government  Instead,  sui  supported,  organizational point  u n i l a t e r a l c o n t r o l and  2.4  —  programmes and  From an  dialectic  selected,  communities  dependents.  their  has  CHHs i n t o  view, t h e r e  is  (centre)  and  i s a structure  of  administration.  THE MANAGEMENT OF CAEE PROGRAMME  A NATIONAL COMMUNITY-BASED HEALTH  It was t h e e x p e c t a t i o n of the project that i t would g e n e r a t e community a c t i o n f o r health. We have s e e n t h a t t h e p r o j e c t has done t h a t b u t w i t h the problem of developing a self-sustaining mechanism. 8 2  Using  the  three  organization, re-construct  and  Ministry  of  phase  moments o f  management,  the  interpretation management  processual  of  CBHC. in  I  have  Health's  This  the  conceptualization,  section  process  of  attempted  to  perception  and  focuses  on  the  implementing  CBHC  programmes. Unfortunately, information of  Health  CBHC  on  has  there  t h i s aspect  programmes  had  two  reports  a limited  of  v i r t u a l l y , no other  and  only the  one  circulation.  brief  On  the  and  programme.  experience i n  than that  P r o j e c t i n Western Kenya. only  is  of Pilot  The  the  the  Ministry  management o f  National  Project,  speech a v a i l a b l e ,  cursory  8 3  and  Pilot  there these  are have  101 Nevertheless,  these  reports  f e a t u r e s of t h e management and  some  o f the  experience the  p r o p o s a l s made  surmised the  that  experience  problems t h a t  of the P i l o t  the  general  f o r the P i l o t  Project  have r e s u l t e d . .  Project  for a  delineate  has f u e l l e d  national  the problems raised  Pilot  provide a rough o u t l i n e  programme, will  i t can  similarly  of  be  occur i n  the s t a t u s o f t h e N a t i o n a l  P r o j e c t i n Community-^Based H e a l t h C a r e ,  figures are given. September,  that  153  districts  The N a t i o n a l P i l o t  1977 i n t h e D i s t r i c t s  Western K e n y a .  8 4  The l a t e s t  health 8 5  while  o f Kakamega  report  the  were  an  report  1979  163 c o m m u n i t i e s .  o f 198,000  South Kabras, Bungoms,  Worker  (CHW)  87  this  formed  of  t o 1,000  Beport.  8 8  the  people,  in  women,  flore  the  two  that  163  were  three locations  of  working  population i n  i n the two d i s t r i c t s  people,  lowering  and Bungoma o f  suggested  a projected  presents a r a t i o  t o 1,200  thereby  Given  for  and B o k o l i )  trained, 1 CHW  people  8 6  started i n  on t h e P r o j e c t i n d i c a t e d  committees earlier  the f o l l o w i n g  Project  Community H e a l t h W o r k e r s (CHWs), m o s t l y  and  the c o n t e n t s of  l a r g e r g o v e r n m e n t programme. To  in  Since the  (Tiriki,  o f Kakamega  1 Community  Health  CHWs w i l l : u n d o u b t e d l y  the f i g u r e  to the proposed  a s recommended  be.  ratio  i n the appraisal  102 2.4.1  Management P r o b l e m s i n t h e P i l o t  The p r o b l e m s t h a t three  general  areas of concern:  experiential, the  are reported  and  an E c o n o m i c Project  Study  in  organizational  [i)  first  relationship  ,  Kenya.  All  8 9  level  organizational  Health  Provincial  Health C a r e . "  between  ;  t o i n Han gombe s a r t i c l e e n t i t l e d ,  Health  other  problems  of  an  i n the  at the Seminar  on  9 0  problem  community  Management  C a r e P i .lot  are presented  P r o v i n c i a l C o m m i s s i o n e r * s "Opening Speech  The  into  The e c o n o m i c p r o b l e m s i n  and e x p e r i e n t i a l n a t u r e  Community-Based  fall  organizational, [ i i )  o f t h e Community-Based  Western  Area  f o r the P r o j e c t  [ i i i ) economic.  programme a r e a l l u d e d  Project  exposes  leaders  Teams.  and  In  the  the the  tenuous District  words  of  the  Commissioner:  Community leaders and their chiefs i n each l o c a t i o n a r e n o t 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 e v e n more results [sic). F o r example; health technicians f o r advice on spring protection; public health officers for improving drainage on r o a d s , etc.; agriculture people t o give a d v i c e ; and c o - o r d i n a t i o n w i t h t h e Ministry of Water Development, , If community leadership takes on t h i s , a l o t more c o u l d be achieved.? 1  This  statement  organizational  identifies links  the inadequate  between  the  communication  community  and  the  and  health  c a r e system i n f r a s t r u c t u r e . The s e c o n d o r g a n i z a t i o n a l the  first.  When  w i t h i n t h e community Community  Accounts)  the  problem i s  organizational  [eg.  Community  i s created  clearly "support"  a r e s u l t of structure  H e a l t h Committees,  by an  external  and  government  101 body,  t h e r e a r e two  dependencies reinforced,  on and  the  (ii)  imposed s t r u c t u r e s Commissioner  noticeable results: formal  (i)  are  t h e r e i s a l a c k o f commitment t o  these  community  bemoans t h e  fact  care  original  system  by  health  the  members.,  The  Provincial  that:  The p e o p l e s t a r t e d o u t w i t h much e n t h u s i a s m b u t i n some p l a c e s p e o p l e a r e s l o w i n g down. This leads to: (a) i r r e g u l a r , s o m e t i m e s p o o r l y a t t e n d e d community h e a l t h committees. (b) p o o r 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  If  in  fact  Committees creation  the  and of  Management  Community the  Teams),  way.  community, persons are  i t  is  the  are  not  perceived to ?)  be and  child's the  Community  (shillings) .  to  adult i s expected  f e e i s 1/=  (shilling).  account  the  out  pay  community [CHWs) i n a in  the  function  of  That i s ,  of  Health  a r e making c u r a t i v e  (CHW)  3/=  they  medicines.  day  and  for services given.  t o pay  the,  Health  M i n i s t r y of  community  (shillings)  night, For and  a  T h i s money i s d e p o s i t e d i n  o f which  Unfortunately,  that  and  purveyors  H e a l t h Worker  patient i s quite willing  be  District  the r o l e  therefore  Community  to  Health  a r e women s e l e c t e d  t r a i n e e s of  demands on t h e  an  felt  government c l i n i c s .  members o f t h e  example,  are  H e a l t h Workers  attributed  Consequently,  a  Community  surprising  Community  a s s o c i a t e d with  of  .through  Even t h o u g h t h e y they  [employees  accounts  government  members e x p e r i e n c e d similar  establishment  the  the  CHW  money  i s paid  50/=  deposited  from  104 curative rate  services i s  f o r the  each  CHW.  household  not  sufficient  a yearly in  the  maintenance  of  the  Commissioner  remarks:  deposit  community account.  to sustain of  10/=  would But  the  monthly  .shillings) contribute  as  the  from  to  the  Provincial  P e o p l e a r e not l i v i n g up to t h e i r own commitment of maintaining a community fund. In some c o m m u n i t i e s , o n l y the amount c o l l e c t e d t o open t h e Community a c c o u n t a t t h e P o s t O f f i c e S a v i n g s Bank i s the o n l y amount s t i l l there, This leads to difficulties of p a y i n g the small allowance of s h i l l i n g s 50/= t o t h e Community H e a l t h W o r k e r s . ? 3  2.4.2  D i s c u s s i o n o f t h e M i n i s t r y o f H e a l t h ^ s Management P r o b l e m s i n Community-Based H e a l t h C a r e (CBHC)  The  management p r o b l e m s  implementing attributed  the  National  to:  (i)  supplementary h e a l t h that the  of  intervention facilities first  were  strategies  offering  cause —  strategy  —  not  previous  the  Pilot  the  care  r u r a l communities light  experienced  imposed  seem t o p e r c e i v e government and  that  i t i s clear responding  that  was  of  Health  Committee  meetings  Community H e a l t h  accounts.  and  an  health  this  new  can  the  fact  system i n  static  health to  the  communities  the For  attendance at in  care  intervention  rural  care."  be this  reference  to  of  of  health  imposed  difficulty  This  (ii)  In  members o f  irregular  and  mission  enthusiastically  there  i n CBHC  b u i l d i n g of  i t was  d i r e c t i v e s of "community-based evidence  the  process  intervention  organization,  (i.e.,  the  Project  curative care)., fact  in  reguired example, Community  sustaining  management p r o b l e m  may  the be  105 attributed  t o the  and  manner i n  In  the  process  which the  instance of  (sponsored  by  o f c o n s t r u c t i o n and health care  the  problem  National  the M i n i s t r y of  Pilot  Health  and  initiative  outside through  the  source  community  words,  any  the  by  conceptualized and  then,  the  community.  the  an  For  and  t o the  community i s  expected  payment o f Community  project, to  directives  necessary  project They  or  community.  events  i  of  is  not  have  not  perceived  need,  that specific  action in  there i s evidence  of a lack  and  support  Health  Nations  as a r e s u l t , the  when  p r o j e c t through  Workers t h e y  are  not  the the  motivated  so.  A second problems  consideration i n  i n CBHC  constructs  programmes  them)  is  the  t h i s supplementary  attributed health care this  reason,  CBHC  from  sequence o f  implemented  this  United  l e a d e r s i n the  members.  in  came p r o f o r m a  a m e l i o r a t i v e a c t i o n to a  organized  addressed.  that  "development"  community  was  i t i s clear  from the  respected  critical  o f commitment  Since  not  community-based  experienced  t o do  of i n s p i r a t i o n  and  d i s c u s s i o n with  In other for  and  provenance  Project  I n t e r n a t i o n a l C h i l d r e n ' s Emergency F u n d ) , the  the  light.  socialized  i n design system,  (as  image  the these  of  Ministry programmes  management of  Health project..;  form of h e a l t h c a r e i s and  organization  to the  i t i s a p p r o p r i a t e d and  Peasants into  the d i s c u s s i o n  in  expecting  the r u r a l  areas  clinically-based  government  experienced  in  o f Kenya  are  health  care.  106 They  are guite  received but  not  from a h e a l t h willing  Furthermore, Workers health  willing  purveyors  worker  i t would are  workers of  pay  for  the  (drugs,  curative  appear  that  perceived of  the  to  oriented  the  be  the  L i k e the  them, t h e y  are experienced  v e r s i o n of the  mainstream  health  problem, t h e r e f o r e , manner i s t h a t health  2-5  the  care  i n constructing intended  focus  as  and  therefore  Health  Field  another  hydrid  worker.,  The  larger  disease  this  prevention  and  p r o m o t i o n programmes i s o v e r l o q k e d .  A Review o f  In  t h i s chapter,  the  Epistemological  I reconstructed  Ministry  organizational,  The  n a t i o n a l CBHC programme s u f f e r s ,  proposed  the  s t r a i n e d and  and  the  Dilemma  conceptual,  competitive  bureaucratic  environment  and  between t h i s  organization  (the  cry  peripheral  DISCPSSIOH OF THE HIHISTBY OF HEALTH'S SOCIAL CONSTRUCTION OF "COHMUNITY^BASED HEALTH CARE"  2.5.1  On  Health  CBHC programmes i n  on  ;  services.  most  Family  Educator before  etc.)  Community  government s y s t e m  medicines.  services  innoculations,  to i n v e s t i n preventive  (CHWs) care  to  the of  while  one  hand,  official  Harambee i n on  the  strengthening managers and  of  relations t o the MOH)  hand,  clinical  CBHC.  I feel,  from  intrinsic  superordinate and  rural  need f o r foster  services.  d i r e c t o r s i n the  Health's  v i e w s on  CBHC  the These  to  the  relation  communities...  p o l i c y makers e c h o t h e  v o i c i n g the  other  management  of  political  programmes,  expansion upper  M i n i s t r y of H e a l t h  are  and level  caught  10.7; in  a  double bind.  approach"  to  profe.ssional full  They s e e t h e  rural  (and  of r u r a l  health  [focusing  promotion a c t i v i t i e s ) of these s e r v i c e s .  doctors,  on  health  sub-^centres, diverted and aid  assistance  summary,  Health  could  Worker  the  (CHW)  "government" h e a l t h made  CHW, the  from  effective that  and h e a l t h  by d e c i d i n g  health  p o l i c y makers  and the  From an e c o n o m i c  generally assist (hospital,  point  i n t h e b u i l d i n g of  health  centres  and  would i n f u t u r e be p a r t i a l l y  Community  seriously  schools  would  p o s i t i o n s (as  professionals)  incurs.  of  to concretize  Health  Workers  This  competitive  threaten  as w e l l ,  {CHWs);  their  and t h e u s u a l  own status  enjoys. In  is  prevention  s t r u c t u r e s f o r CBHC.  professional training it  disease  and d i s p e n s a r i e s )  supportive  their  them  of the  own p r o f e s s i o n a l  facilities  to the t r a i n i n g  other  terms  t o CBHC,  and o t h e r  v i e w , t h e monies t h a t  static  but  s e r v i c e s , they r e a l i z e  Nevertheless,  r i g h t s and p r i v i l e g e s t h i s of  services  a c t u a l l y s u p p o r t s t h e i n t e l l i g e n t use  status of their  nurses,  In  care  p o l i c y commitment  reduce the  a "two-pronged  i n t e r e s t s dissuade  commitment.  a CBHC programme  a formal  care  political)  and h o n e s t  utilization  health  need f o r  directive  that  of Health-trained  i s perceived care  responsible  the fact  Ministry  worker.  t o be j u s t  another  "supporting"  i t i s the Ministry of Health the  CHW  k i n d of  E v e n t h o u g h t h e community  f o r " s e l e c t i n g " and  makes  Community  and  the  CBHC  that  their issued  programme  a  108 government i s s u e . been  Historically,  responsible  service.  f o r providing  With the i n i t i a t i o n  CBHC programme,  programmes.  As s u c h ,  capable  villages.  of  leaders  (those  often  o f t h e MOH  prepared  of  the  CBHC,  a  care  clinical,  t h e CHB i s curing  care  and  perceived treating  following  opportunity  tensions  (i)  t o be a people  a s CHWs) about t h e  i n the  community  and r e p r e s e n t a t i v e s goals  and o b j e c t i v e s  f o r sustained  and  "mutually  possibility.,  the Ministry of Health  and o p p o s i t i o n s  "local  dialogue,,  n e e d s between r e s p e c t e d  to talk  r e l a t i o n a l terms,  (education),  been an e n c o u n t e r ,  selected  of a  the actual  prevention  s u p p o r t e d " CBHC programmes would emerge a s a In  health  image o v e r r i d e s  and d i s e a s e  However, h a d t h e r e  o r exchange o f h e a l t h  has  {unilateral intervention)  curative  p r o m o t i n g FB  motive of  doctor"  this  the M i n i s t r y o f Health  contains the  t o w a r d s CBHC:  professional/politico-economic and  (ii)  curative/disease family  prevention,  health  p r o m o t i o n , and  planning or  clinic-based/community-based  health  care.  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 who a r e e n c u l t u r a t e d knowledge clinical  - - which  i n a biomedical i s actualized  facilities  competition  with  the  offering  system  in  of health  the construction  curative  £olitical  and n u r s e s  care  philosophies  —  care of  i s in, (Harambee,  109 self-help  development)  (aid-related  financial  which emphasizes family, planning exacerbated  administration for  the the  Indeed,  on  "broad-based" contradict The  contradictions  2.5.2  Health.,  and are  bureaucrat t i g The  :  reduces the  and a u t h e n t i c  within  the  top-heavy  possibilities  CBHC programmes.  This  relation;  the  Ministry  wholeness  development  these  apparent  adequately  and  —  bureaucracy/community  officials  eloquent  of  severely  suggests a t h i r d c o n f l i c t i n g (iii)  health promotion,  Furthermore, these t e n s i o n s  Ministry  unique  requirements  CBHC programmes  organizational  o f t h e MOH  implementing  of  prevention,  programmes.  of  economic  conditions)  disease  by  limitations  and  and  efforts  and  within  wax  worthwhileness CBHC,  MQH  of  this  is  of  and  government  the  the d u p l i c i t y  H e a l t h may  through  statements i n actual dilemma  of  yet  policy. * 9  that  situation  these i s not  resolved..  A Critical  Problem  i n the I m p l e m e n t a t i o n  of a  Government " C o m m u n i t y - b a s e d H e a l t h C a r e " Programme These in  v a l u e s and  the tensions  the person o f the  t h e CBHC imposition  they i n v o k e  are  Community H e a l t h Worker  programmes a r e  perceived to  of the government,  as "government" h e a l t h c a r e and  supposedly remunerated  and  work i s a t t r i b u t e d  the  (CHW).,  be t h e  Since  creation  CHWs a r e a l s o  workers.  refracted  and  identified  Even  though  selected  by t h e community,  their  position  t h e same  meaning and  subsumed  by  the  110 same  c o n f i g u r a t i o n of  Ministry  of Health.  doctor:"  a health  d r u g s ) who  care  rank  file  work  of  persons,  with  they  dawa  members  who  who  aligned  more  are  worthwhileness scale  away f r o m  are  through  They  the ranks moral,  of the  are persons  who  from  the  not p a i d  for  immediately  to  civil  For  service  subscribe  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  —• i n d i c a t e d  part-time  and community s t r u c t u r e s  Consequently,  as CHW  As  for  and r e s p o n s i b i l i t i e s .  and t i t l e  capacity  "local  [Kiswahili  status, role,  their  as the  the  i s a p p r e c i a t e d a s advancement on t h e  traditional,  accountability.  that of  are separated  community  values, o b l i g a t i o n s ,  professional and  of  and  traditional t h e CHW,  worker  t r e a t s and c u r e s i n t h e community.. professional  their  values as  The CHWs a r e e x p e r i e n c e d  salaried, and  health care  to the  o f government " h e a l t h c a r e w o r k e r . "  i s non-equivalent  that occur i n  and n o n - r e c i p r o c a l  by 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 .  diagnosis,  prescription,  rendered. to  That  community  symbolized progressive  a  payment  for  services  As s u c h , t h i s r e l a t i o n s h i p  of  CHW  members i s b r o k e n and d i s c o n t i n u o u s , and c a n be  with  (x=±).  involvement  relationships broken,  i s all.  and  with  the  On t h e o t h e r i n work  r e l a t i o n s h i p s o f t h e CHW  with  Ministry  and c a n be s y m b o l i z e d  hand, b e c a u s e o f  are  with  t o community  the  Ministry,  continuous  (___s)«  their their  and  not  In t o t a l ,  the  members and t h e  111 government h e a l t h  care system  government health care infrastructure Ideally, two  the  health  care  who  necessarily  forced  predictable)  as  negotiating  both  capacity  deliberate  but compelled  to transcend  initiated,  often  a c c e p t a b l e t o community  government  the  and  managed  capable  i s one  programmes.  on  —  of and  emerge  in  Rural  they  are a  inaction  and  they a r e always terms  that  are  members.  case that  the  i n t e n t on i m p l e m e n t i n g  problem  3)  But whatever t h e motive,  organized,  i t i s  {see c h a p t e r  to  these  Self-sustained  CBHC programmes  Project  reaction  ineffectiveness.  seriously  are not  { o r d e r e d and  individuals,  worlds.  made  t h e community  contexts  reasons of  i s  Sometimes - - a s i n t h e c a s e o f t h e S a r a d i d i  H e a l t h Development  If  these  o f the  and d i a l e c t i c  furthermore,  CHHs i n  authentically-constructed  CBHC  communication,  epistemological  i n the  way.  community)  t o a c t as persons f u l f i l l i n g  differences  this  {that  r o l e s i n one s y s t e m o r a n o t h e r ,  moral and  the  and t h e  the dialogue,  emerge  and r e c o n c i l i n g  i n CBHC programmes  i s t o l e r a t e d b e t w e e n them.  leaders  by  systems  community members  f o r mediating  infrastructure  p o s s i b l e through that  \ CHHs /. o t h e r s  opportunity  organizational  can be diagrammed a s f o l l o w s :  o f how t o Initially,  Ministry  of  Health  i s  a n a t i o n a l CBHC programme, protect the  and  safeguard  problem  posed  these by  112 researchers associated  working with  on  provide yet,  taken  National  the M i n i s t r y ,  p r o c e s s o f "community recourse  the  by  was how  M i n i s t r y of  the organizational  model  Health  the  officials  was  (Ministry  (community-based)  mutually  supportive  i t ,  supportive  this  care  systems i s s t i l l  i s the  (assuming, o f c o u r s e , to defer  health  that  and  to  the  between these  the relationship  infrastructure)  and  systems develop  into  t o be d e t e r m i n e d .  negotiation  critical  the  and  The p r o b l e m o f how  of Health  articulation  systems  useful links  i n s u c h a way t h a t  informal  shed  to f a c i l i t a t e  f o r CBHC programmes,  Government a n d t h e Community..  between t h e f o r m a l  the  and  i f t h e above i s s u e s a r e t a k e n i n t o c o n s i d e r a t i o n ,  l i n k s c a n be c o n s t r u c t e d  see  Project  p a r t i c i p a t i o n , " : a s was e x p l a i n e d ,  p r o b l e m becomes one o f how t o c o n s t r u c t the  Pilot  of  mutually  organjzationa.l  the Ministry of Health  as I  problem  i s willing  c o n t r o l o f t h e p e r i p h e r a l arm o f CBHC programmes t o  communities t h e m s e l v e s ) . light  on  considerations.  these  The  case studies  organizational  and  that  follow  epistemological  113 ENDNOTES J o s e p h K. Wan*gombe. E c o n o m i c Study, o f t h e Community. B^sed H e a l t h C a r e P i l o t P r o j e c t i n Western Ken y a , 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. 29. Cf. as w e l l : M i r i a m 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 R e p o r t on t h e 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 C a r e -- A Kenyan. Experience (Nairobi: M i n i s t r y of H e a l t h / Department o f Community Health, Faculty of Medicine, University of N a i r o b i , 1979), A p p e n d i x , p. 5. I view " c o m m u n i t y - b a s e d h e a l t h c a r e " (CBHC) a s an ejrent i n t h a t i t i s c o n s i d e r e d t o o p e r a t e a s an i d e a , experience,, and intervention that threatens o r undermines existing premises and r e l a t i o n s i n t h e M i n i s t r y o f H e a l t h and t h e r e f o r e demands some f o r m o f r e s o l u t i o n , mediation, or compensation. Although the Republic o f Kenya does not have a formal p o l i c y r e g a r d i n g Primary Health Care (PHC) o r CBHC a s in, o t h e r 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 t h e M i n i s t r y of Health - Headquarters suggests that the recent Integrated Rural Health and F a m i l y Planning Programme [IRH-FP) agreement c a n be c o n s i d e r e d a CBHC policy statement [Personal interview with A s s i s t a n t Deputy D i r e c t o r of M e d i c a l 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 o f 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 [ N a i r o b i : Republic o f ~ K e n y a , 1981) 7~*P• "74. U n i t e d S t a t e s Agency f o r I n t e r n a t i o n a l D e v e l o p m e n t , Kituj Feasibility study Report (Nairobi:, USAID M i s s i o n • • to. Kenya, 1981), p. 42, e m p h a s i s added. Janovsky examines t h e e x p e r i e n c e , 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 level manager and administrator — i n the bureaucratic setting of the headguarters of M i n i s t r y of Health, N a i r o b i . , Cf. Gerlinde Katarina Janovsky, Organizational Transaction and B a r g a i n i n g : H e a l t h i n K e n y a , " D i s s . H a r v a r d 1979.  "Planning as The C a s e o f  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 T a n z a n i a , e d . J o e l D. B a r k a n , w i t h J o h n J . Okumu (New Y o r k , London, S y d n e y , Toronto: Praeger P u b l i s h e r s , 1979), p. 130. Ibid.:  135.  114 Gerliude Katarina 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 C a s e o f H e a l t h i n K e n y a , " D i s s . H a r v a r d 1979, p . 85.  9  10  I.E. Mburu, M i c k e y C. ... S m i t h , and Thomas B. , S h a r p e , "The Determinants of Health S e r v i c e s U t i l i z a t i o n In a Rural Community i n Kenya," S o c i a l Science and M e d i c i n e , 12 (1978)., pp. 211-217.  11  Ecosystems Limited, "Kauwi-Kathibo fiural Health ; Unit, R u r a l H e a l t h S e r v i c e s S t u d y " ( N a i r o b i : n.p., 1979).  1 2  according to t h e 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 r e c o r d , , 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 o f H e a l t h , P r o p o s a l f o r t h e JjHproye.ae.nt o f R.ur.a.1 Health Services and t h e Development of Rural Health T r a i n i n g C e n t r e s i n Kenya (Nairobi: R e p u b l i c o f Kenya, M i n i s t r y o f H e a l t h , 1 9 7 2 ) , 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 o f H e a l t h and D i s e a s e , " i n H e a l t h and D i s e a s e i n Kenya, e d . L.C. V o g e l , 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 t h e s e r e s e a r c h needs: i)  utilization  of h e a l t h s e r v i c e s ,  ii)  e x p e c t a t i o n s and  iii)  reasons for defaulting l o n g - t e r m t r e a t m e n t s , and  iv)  reasons for what i s c o n s i d e r e d demand f o r some s e r v i c e s and too other s e r v i c e s (Ibid.:72-73).,  satisfaction  among p a t i e n t s ,  both  short-term  and  an excessive low demand f o r .  i*  M i n i s t r y o f H e a l t h , P r o p o s a l f o r t h e Improvement of. R u r a l Health Services a n d th_e figyglopment of Rural. Health, g r a i n i n g C e n t r e s i n Ken ya (Nairobi: R e p u b l i c o f Kenya,. 1 s t A u g u s t J 1972),~p7 2."  is  Ibid.:4.  is Gerlinde Katarina Janovsky, " P l a n n i n g as O r g a n i z a t i o n a l Transaction and Bargaining: The Case of Health in K e n y a , " D i s s . H a r v a r d 1979, p. 144. I T fhe a d m i n i s t r a t i o n of M i n i s t r y carried out at four levels: D i s t r i c t , and R u r a l . alternatively the structure  of H e a l t h activities is Central, Provincial, could  be  described  as  115  1  is  central, intermediate (provincial and d i s t r i c t ) , and peripheral (rural). S. K a n a n i , K e n y a ' s M a t e r n a l , C h i l d H e a l t h / F a m i l y 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 H e a l t h , April 1979), p . 1. I n t h e R e p u b l i c o f Kenya, t h e r e a r e f o r t y Districts, each o f which i s s u b d i v i d e d into Divisions, 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 . ) . Gerlinde Katarina Janovsky, " P l a n n i n g as O r g a n i z a t i o n a l Transaction and B a r g a i n i n g : The C a s e of Health i n Kenya," D i s s . H a r v a r d 1979, p, 147.  »9 I b i d . :  150.  zo I b i d . :  164.  2* R e p u b l i c o f Kenya, Development P l a n 1979-j[983, (Nairobi: Government P r i n t e r , 1979), p p . 48-51.  Part I I  22 R e p u b l i c o f Kenya, Development P l a n 1979-1983. (Nairobi: Government P r i n t e r , ?979) , pT~T27"  P a r t 3. ~ ~"  23 I b i d . :  136.  2* Gerlinde Katarina Janovsky, "Planning as O r g a n i z a t i o n a l Transaction and B a r g a i n i n g : The Case of Health i n Kenya," D i s s . H a r v a r d 1979, p . 156. 2  5  Rural Health Development Project (RHDP) and Administrative Support Unit (ASU), Integrated Rural Health S e r v i c e s Programme: Working S e m i n a r (Nairobi: M i n i s t r y o f H e a l t h , 25-26~May, 1978), p.~T.~  2* I b i d . ; 2  7  as  31.  M i n i s t r y o f H e a l t h a n d Department o f Community H e a l t h , Primary Health Care: Kenya Bxpjerience (Nairobi: 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 o f N a i r o b i , August 1 9 7 8 ) , p . 11. Ibid.  2» I b i d . ;  13.  3 0 H.M. Mule, P r e p a r a t i o n o f I n t e g r a t e d R u r a l H e a l t h Programme [Nairobi: Ministry of Health, 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 o f H e a l t h , P l a n n i n g Programme: 10, 1979) , p.~T. 32  Ibid.  a n d FP RHDP,  Integrated Rural Health and F a m i l y Working Document ( N a i r o b i : August  116 3  3  Ibid.:  4,  emphasis  added.  3 4  M i n i s t r y of Health, The Integrated Rural Health and Family P l a n n i n g Programme, A p p r a i s a l Report [Nairobi: R e p u b l i c of K e n y a , A p r i l 1981), p. 74.  3 5  Moris (1976) guoted i n Gerlinde Katarina Janovsky, "Planning as Organizational Transaction and B a r g a i n i n g : The C a s e o f H e a l t h i n Kenya," D i s s . H a r v a r d 1979, p . 58.  3 6  Ministry of Health, The Integrated $ u r a l Health and Family P l a n n i n g Programme, Appg§i§al Report (Nairobi: R e p u b l i c of K e n y a , A p r i l T981) , p. 78. "*  3 7  M i n i s t r y of Health, Primary Health. C a r e : Tanzania E x p e r i e n c e (Par e s S a l a a m ; The Government P r i n t e r , The U n i t e d R e p u b l i c of T a n z a n i a , 1978).  3 8  A b d e l Bah man K a b b a s h i , ghe S t a t u s of £ r i m a r y {jj ea.lt h £§.£§. i n Sudan (Khartoum: M i n i s t r y o f H e a l t h , May 1978).  3  Khanali s t a t e s that: less than 15% of the rural population and other underprivileged people are reached by established health 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 H e a l t h C a r e ; Speech on Community Health Carjs t o F.£2.yincial Seminar with Provincial Heads as P a r t i c i p a n t s (Western Province: M i n i s t r y o f H e a l t h , 3 December 1979), p.... 1..,.  9  D r . M. Migue and L.K. Ndungu p o s i t t h a t " o n l y 20-302 o f the r u r a l population actually b e n e f i t from and utilize rural health services." See; M. Migue and L.K. Ndungu, R u r a l H e a l t h Management the Kenyan E x p e r i e n c e (Nairobi: M i n i s t r y of Health, ?979) 7~P22. F i n a l l y , M i r i a m K. Were s t a t e s t h a t " p o p u l a t i o n c o v e r a g e w i t h h e a l t h s e r v i c e s i s o n l y a b o u t 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 R e p o r t on t h e N a t i o n a l P i l o j : Project i n Community-Based Health Care -A Kenyan Experience [Nairobi: 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 t h e Improvement o f EU£&1. Health Services and t h e Development of Rural Health T r a i n i n g C e n t r e s i n Kenya (Nairobi; 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 D e v e l o p ment o f S i x Rural Health T r a i n i n g C e n t r e s [Nairobi: Ministry of  117 Health, 4  2  1979).  J o s e p h K. Wan'gombe, Econoaic Study of t h e Community Based Health Care Pilot P r o j e c t In Western Kenya, Institute of Adult Studies [Nairobi: University of N a i r o b i , 1980), p. 2. Cf. as well, S u r a l Health Development Project and Administrative Support Dnit, Integrated Rural Health S e r v i c e s Programme: Working Seminar ( N a i r o b i : Ministry o f H e a l t h , 25-26 May 1978).  4  3  Evaluation/Research C e n t r e , A R e p o r t on (Nairobi: Ministry  Division, National Family Welfare the A c t i v i t i e s of the F i e l d Educators of H e a l t h , June~1978).~~  4  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 P r o j e c t Request Report: The C o n s t r u c t i o n and D e v e l o p m e n t o f s i x Rural Health T r a i n i n g Centres (Nairobi: Ministry of H e a l t h , 1979), p. 16.,  4  5  S. Kanani, Kenya's R u r a l Health Services M i n i s t r y of Health, Development P r o j e c t s f o r H e a l t h S e r v i c e s , 1980), p. 11.  (Nairobi: the Rural  •*  S. Kanani, Kenyans Maternal, Child Health / Family Planning (MCH/FP) Programme (Nairobi: Ministry of H e a l t h , A p r i l 1 9 7 9 ) , p. 9.  4  7  Evaluation/Research Division, National Family Welfare Centre, A Report on the Activities of the Field Educators, 1978 (Nairobi: Ministry of H e a l t h , June 1978) , p. 2.  4  8  Republic of Kenya, Development E__a.n 1979-1983., (Nairobi: G o v e r n m e n t P r i n t e r , 1979), p.,131.,.  4  9  Evaluation/Research Division, National Family Welfare Centre, A Report on the Activities of the Fj^ld Educators, 1978 (Nairobi: Ministry of H e a l t h , June 19 78) 7~p. 2.  s  0  Ministry of Health, Family Health Field (Nairobi: M i n i s t r y o f H e a l t h , n . d . ) , p. 1.  Part  Educators  3 1  Evaluation/Research Division, National Family Welfare Centre, A Report on the Activities of the Field Educators, 1978 (Nairobi: Ministry of H e a l t h , June 1978), p. 9.  5  Evaluation/Research Division, National Family Welfare Centre; Research/Evaluation Unit, Family Planning A s s o c i a t i o n o f K e n y a , An E v a l u a t i o n o f Eie__d fidjica.tors in, Kenya - t h e Work L o a d (Nairobi: M i n i s t r y o f H e a l t h and  2  118 Family 32 and 53 5  4  5  5  a*  Ibid.:  Planning 48.  a s s o c i a t i o n of  Kenya, November  1979) ,  pp.  11.  S. Kanani, Kenyans B u r a l Health Services M i n i s t r y of Health, Development P r o j e c t s f o r H e a l t h S e r v i c e s , 1 9 8 0 ) , p. 11. fl. Migue and L.K. Kenyan E x p e r i e n c e p . 19.  (Nairobi; the S u r a l  Ndungu, R u r a l h e a l t h Management -- the. {Nairobi; M i n i s t r y of Health, 1979),  Ibid.,  5 7  M i r i a m K. Here, E e o j l e i s 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 g e p g r t on the. N a t i o n a l P i l o t P r o j e c t in qommunity-Based H e a l t h C a r e -a Ken.ya.n Experience. (Nairobi: M i n i s t r y of Health/Department of Community Health, Faculty of Medicine, U n i v e r s i t y of Nairobi, 1979) , p. 8.  se  ibid.;  5  See: Ministry of Health, Integrated Rural H e a l t h and Family P l a n n i n g Programme (IRH2FP): appraisal Report (Nairobi: K e p u b l i c of Kenya, a p r i l 1981).  9  *o I b i d . : 61  Ibid.  62  ibid.  2-3.  75.  6 3 M i r i a m 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 P r p j e c t j in Sommunity-Based H e a l t h C a r e -a Kenyan Exp_erienc§ (Nairobi: M i n i s t r y of Health/Department of Community Health, Faculty of Medicine, U n i v e r s i t y of Nairobi, 1979) , p. 32. Cf. as s e l l , 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 , P r i m a r y H e a l t h C a r e ; Kenya E x p e r i e n c e (Nairobi: 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 , a u g u s t 1978), p. 15. 6*  M i n i s t r y of H e a l t h and Department o f community H e a l t h , Primary Health Care: Kenya Experience (Nairobi: M i n i s t r y of 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 , a u g u s t 1 9 7 8 ) , p . ,13.  6s  ibid.  66  Rural  Health  Development  Project  (SHDP)  and  119 administrative Support Unit Health S e r v i c e s Programme: M i n i s t r y o f H e a l t h , 25-26 May,  (ASU) , Integrated Sural Working S e m i n a r (Nairobi:.  1978)*,  p7~T9,~""  7  Ministry Primary Ministry Nairobi,  of H e a l t h and Department o f Community H e a l t h , Health Care: Kenya Experience [Nairobi: of H e a l t h / F a c u l t y o f Medicine7~ U n i v e r s i t y o f A u g u s t 1978) , pp. 13-14.,  6 8  Ministry Primary Ministry Nairobi,  of H e a l t h and Department o f Community H e a l t h , Health Care: Kenya Experience (Nairobi: o f H e a l t h and F a c u l t y o f M e d i c i n e , U n i v e r s i t y o f a u g u s t 1978), p . 11.  6  9  M i r i a m 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 R e p o r t on t h e N a t i o n a l P i l o t P r o j e c t in Community-Based H e a l t h C a r e -I Kenyan Experience (Nairobi: M i n i s t r y of Health/Department of Community Health, Faculty of Medicine, U n i v e r s i t y of Nairobi, 1979) , p. 4.  7  0  6  Ibid.  7 1  See t h e c h a p t e r on t h e 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 " a r e 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 H e a l t h Committee w h i c h manages the Project's a f f a i r s i n t h e i r area.  7  2  The r a t i o n a l e f o r u s i n g the social unit o f "community" o v e r and above " v i l l a g e " o r " c l a n " w i l l become c l e a r e r i n t h e two c a s e s t u d i e s t h a t f o l l o w .  7  3  The Sepublic of Kenya is divided into these administrative units; Provinces, D i s t r i c t s , Divisions*. L o c a t i o n s , and S u b - L o c a t i o n s . V i l l a g e s are the informal units w i t h i n the s u b - l o c a t i o n and are administered 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  *  M i r i a m 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 R e p o r t on t h e N a t i o n a l P i l o t P r o j e c t in Community-Based H e a l t h C a r e --- A Kenyan Experience (Nairobi: M i n i s t r y of Health/Department of Community Health, Faculty of Medicine, U n i v e r s i t y of Nairobi, 1979) , p. 5.  7  s  7  6  ibid. Rural Health Development Project and Administrative S u p p o r t U n i t , I n t e g r a t e d R u r a l H e a l t h S e r v i c e s Programme: Working S e m i n a r ( 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. 77  ibid.:  7«  F a r i i c e M. K h a n a l i , "Community-Based H e a l t h C a r e , " Speech on Community Health Care t o P r o v i n c i a l Seminar with Provincial Heads as P a r t i c i p a n t s , Western Province, December 3, 1979, p . 3.  7 9  Ibid.:  31.  3.  Ministry of Health, 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:. R e p u b l i c o f Kenya, A p r i l 1981) , pp. ,74-75. ,  8  0  8  *  M i r i a m 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 R e p o r t on t h e N a t i o n a l P i l o t P r o j e c t in Community-Based H e a l t h Care ~ A Kenyan E x p e r i e n c e (Nairobi: M i n i s t r y o f H e a l t h / D e p a r t m e n t o f Community Health, Faculty of Medicine, University of Nairobi, 1979) , p p . 13-14.  8  2  J o s e p h K, Wan'gombe, Economic S t u d y o f t h e Community Based Health Care Pilot Project I n • Western Kenya, Institute of Adult Studies (Nairobi: University of N a i r o b i , 1980), p . , 3 4 .  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 C o m m i s s i o n e r ' s (J.G. Mburu's) appended t o t h e Were a r t i c l e . ,  8  *  speech i s  J o s e p h K. , wan'gombe. E c o n o m i c S t u d y o f t h e Community, Based Health Care Pilot Project I n Western Kenya, Institute of Adult Studies [Nairobi: University of N a i r o b i , 1980), p. 1. ibid.:  2.  *  M i r i a m K. Were, People's Participation i n their Health Care: A P r e l i m i n a r y R e p o r t on t h e Nationa.1 P i l o t P r o j e c t in Community-Based H e a l t h Care A Kenyan Experience [Nairobi: M i n i s t r y o f H e a l t h / D e p a r t m e n t o f Community Health, Faculty o f Medicine, University of Nairobi, 1980) , p. 14.  8  7  ibid.:  8  8  Ministry o f Health, The I n t e g r a t e d Family P l a n n i n g Programme, Appraisal R e p u b l i c o f Kenya, A p r i l 1981), p . 7 6 .  8  9  J o s e p h K. Wan'gombe, Economic S t u d y o f t h e Community. Based Health Care Pilot Project I n Western Kenya, Institute of Adult Studies (Hairobi: University of N a i r o b i , 1980).  8  5. Rural Health andj Report (Nairobi:  121 M i r i a m K. Here, People^s P a r t i c i p a t i o a i n their Health Care: A P r e l i m i n a r y R e p o r t on t h e N a t i o n a l P i l o t P r o j e c t ; la Community-Based H e a l t h C a r e -A Kenyan Experience, (Nairobi: M i n i s t r y of Health/Department of Community Health, Faculty of Medicine, University of Nairobi, 1980) , A p p e n d i x ,  9  0  9  »  ibid.:  «z  Ibid.  4.  9  3  M i r i a m 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 t h e Nationa.1 P i l o t P r o j e c t in Community-Based H e a l t h C a r e -A Kenyan Experience (Nairobi: M i n i s t r y of Health/Department of Community Health, Faculty of Medicine, University of Nairobi, 1979) , p . 4.  9  *  F. M. Mburu c a l l s t h e 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 t h e " r h e t o r i c ^ i m p l e m e n t a t i o n gap." S e e : F. M. Mburu, " R h e t o r i c - I m p l e m e n t a t i o n Gap i n H e a l t h Policy and Health Services Delivery for a Rural Population i n a Developing Country," S o c i a l S c i e n c e and M e d i c i n e , 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  in  community-based constructed  (SRHDP) and  health  by an  community.  Asembo  care  hospital,  Republic  (CHW)  has not only  programme  promotion, clinical the  it  and  support  family  CBHC  structure  1  It i s  i n every  the S a r a d i d i  prevention,  b u t has  innovation  and  -  of this  unique-  self-determinism, with:  through the  organizations  122 -  health  c r e a t i o n of  study, f o r c o m p a r i s o n  non-government  Worker  c o n s t r u c t e d the  In l i g h t  are i n i t i a t e d  CBHC  mission  as w e l l through t h e  a u s e f u l case  interventions of  only  East  of g o v e r n m e n t ,  development e f f o r t :  help" c l i n i c .  programmes t h a t  o f Asembo  i m p l e m e n t e d a Community H e a l t h  o f community-based  provides  peasant  initiated  aid organization.  planning,  being  has b e e n  emphasizing disease  Saradidi "self  example  rural,  a  Development P r o j e c t  o f Kenya t h a t  r e s p e c t a "community-based"  i s  i s perhaps the  external intervention or  where  programme  i t i s known i n t h e community  research,  community  occasion  (CBHC)  West s u b - l o c a t i o n s —  the  an  S a r a d i d i Rural Health  programme i n t h e without  chapter  independently-organized,  The  :— a s  this  (i)  strategic  (see c h a p t e r  123 4),  as w e l l as with  government t h r o u g h The  intention  (ii)  t h e model f o r CBHC p r o p o s e d  the M i n i s t r y o f Health  of t h i s  Saradidi  CBHC  2£2§ai2ational programme, its it  early  the  programme,  and  structure that  time  management section,  begun  a year  to  has  —  I  am  issues of however,  Executive  Committee  framework  the  t o manage the.  programme was s t i l l i n I was i n t h e f i e l d  to  into  the area f o r  address The a  —  the  long-term  organizational  discussion of  the  o f t h e P r o j e c t D i r e c t o r (PD), t h e the  Village  Health  H e l p e r s Towards H e a l t h  of e l u c i d a t i n g o f the  down  (EC),  (VHCs), and t h e V i l l a g e  describe  emerged  programme-  breaks  and a c t i v i t i e s  (ii)  t o my v i s i t i n g  unable  the  experience  process  prior  ( i ) r e c o n s t r u c t the  f o r t h e development o f the  stages of development while  first  the  process  S i n c e t h e S a r a d i d i CBHC  had o n l y  (see c h a p t e r 2 ) .  chapter i s toe  h i s t o r i c a l and c o n c e p t u a l  by t h e  the conceptual  Project,  I  Committees  fVHsTH).  In  and o r g a n i z a t i o n a l  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 d e t e r m i n a n t s  that influence the participation  o f members i n t h e 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) . In s p i t e CBHC  programmes  evidence  4).  peasant  i t s independent that  of similarly  development and  of  experience The L u o  economy,  stance  a r e emerging  in  derived tensions of P r o j e c t  community  as such,  in  relation Kenya,  which  members  of Saradidi  they e x p e r i e n c e  t o other there  i s  i m p i n g e on t h e  (see c h a p t e r s 2 i s involved  ina  the discrepancies  12% and  p r e s s u r e s of  and  threatens to  values.  These  process  of  the  Luo,  moral  For  teachers, Project This most  new  disjunction  u n f a i r to  in  in  the  and  leadership  Simply  —  they  Committee  the  feel  (EC) .  readers,  c l a n group  maintain  that  these  g o o d " and  that  i t be  leaders of  (in  in  the  these  structures the  tensions —  objectives —  who  are  the  who  new  of  persons i n  and  attendant  the  Executive  rewards  should  accomplished It  parish  elders,  discrepancies self-serving,  the  each lay  "community  spirit  in  in  alternatively,  w i l l become c l e a r i n  and  would  leaders,  serve the  i n the  by  professional  status  are  is  i s somewhat  a l l  these f i n a n c i a l  elders  benefits  i n t e r e s t of  of  members  [ d h o o t i n Luo)  between a  articulated  although i t  s e e k i n g the  that  Project  income-generating p r o j e c t s  traditional  egalitarianism.  of  tension  businessmen,  t o the  generalizations  They s a y  The  that  of  CBHC  elders  professionals  given  i s owed them as  village.  that  and  stated  generated through the  and  other  the  Saradidi  element of  elite  based  affect  between t r a d i t i o n a l  goals  have b e e n a c c u s e d 2  the  e x i s t s an  professional  make s w e e p i n g  t h e s e groups  salary  influences  area.  these persons.  be  structure the  dramatically  implementing  headmasters,  evident  elite  separations and  which  traditional subsistence-  example, t h e r e  leadership  jodonqo) and  complex economy  fragment  creating  programme. in  a modern,  of  altruism  this  chapter  accountability  personal  larger community—  focus  is a  and  central  125 issue  i n the  understanding of  Development P r o j e c t . work  in  the  of  traditional that  of  i s  atomistic  of  bonds;  titles,  seem  other  the  "community-based  health  in  order to  transcend  their  people  revitalized  of  care"  Saradidi  felt-needs., of  the  Saradidi  identified  as  a  them t o  collectivity  Project.,  have c o n t r i b u t e d  area  one group,  actor,  They will  { i . e.  need t q  of  the Project  i n the Saradidi  to  and  church  g r o u p s t o meet Rural  workers i n  Health  Health  t h e SRHDP  the construction  £egs. t h e Community  their  community),.  { i . e . independent  While c e r t a i n  as a  the boundaries  the in  to  believe  and  amelioration  w i t h c l a n and c h u r c h  more e x p l i c i t l y  S a r a d i d i CBHC programme  they  t h e y have d e f i n e d  of persons  perceived  differences,  the  get involved  and negotiated  Development  no  at  Project  be s o , b u t  have  together.  potential non-participants  persuaded groups),  work  As a r e s u l t ,  [egs.,  a s a n e v e n t and o p p o r t u n i t y  and r e l i g i o u s  community  over  influences  "develop themselves,"  rival  words,:  and a d v a n c e m e n t ) .  accomplish a worthwhile e n t e r p r i s e that  and  to prevail  T h e r e a r e a number o f r e a s o n s why t h i s s h o u l d fundamentally,  Health  integration in  self-serving  Rural  dominant f o r c e a t  the  authority  and  status,  the  towards  community  structures  professional  Saradidi  Nevertheless,  Project  strengthening  the  o f the  Workers),  o r c a d r e o f workers can t a k e t h e f u l l  credit  f o r the  successful  SRHDP.  I t i s a community  development  project.  {to  date)  of  the  126 A  significant  re-emergence  The n y a m r e y u a .  traditional health  healer  who  was  attendant). have  the  ( i n the  and  selecting  members  Many o f t h e s e Committees  i n t o the  as t h e £atron  organizations  and g r o u p s  research  this capacity,  held  community by  crisis,  the l a b i l o  4  Health Helpers been  of o r g a n i z i n g  their  clan  o f the care  Project:  worker  (the  their  area,  needs o f  project.  Village  Health  W h i l e t h e c h i e f o f Asembo  newly  elected  I n former  of the Project  Projects  area  and government  t o the r o l e times during  appeared as the s p i r i t u a l  Health  r e l a t i o n s with  t h e P r o j e c t D i r e c t o r h a s assumed  similar i n function  most  have  and f a c i l i a t e  outside  who  (in  Community  respective  the  organizations,  the. j a b i l o .  birth  of the S a r a d i d i Rural  (SRHDP),  come t o m e d i a t e  been  income-generating  i n the Project.  Project  c u l t u r e (a  elders  health  j o d o n g o s i t on t h e  h a s emerged  and  community  have  activities  an a p p r o p r i a t e  roles  named V i l l a g e  the s p e c i f i c  D i r e c t o r has  the  past  t r a i n e d as  representative  (VHCs)  Development  In  the Saradidi  i n the  the  traditional  jodongo o r l i n e a g e  identifying  initiating  donors,  and  been  was t h e name f o r  p r a c t i t i o n e r i n Luo  persons i n  The  has  traditional  SRHDP t h e y h a v e been  their  nyamrerua).  East  of  with t h e r e s p o n s i b i l i t i e s  village  and  process  f o r example,  p e r s o n s t o be  Towards H e a l t h ) . invested  this  herbalist  a s nyamrerua  instances)  3  care  both  Those  worked  Workers  in  and r e v i t a l i z a t i o n  positions. the  element  (egs.,  agencies).. a role i n  traditionally a period  of  and c h a r i s m a t i c  127 leader groups  who  organized  (gweng)  (oganda  the  into  the  separate larger  or c o m m u n i t y ) .  Project Director i s  In  i n negotiations  political,  expatriate)  Project.  While the  advancing  the  with  territorial the  subtribe  situation, the  the,  interests  authorities  o u t s i d e of the  of  (economic*  boundaries  of  the  P r o j e c t D i r e c t o r i s n o t 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 s t i t u t i o n s and  of  present  to r e p r e s e n t  t h e community and  community  the  expected  clan-based  i n the c o n t e x t  roles being  revitalized  CBHC programme,  he  of t r a d i t i o n a l f o r the  does f u l f i l l  Luo  purposes of an  analogous  function. The  crisis  desperately  in  felt  the  Saradidi  problems  of  unemployment, m a l n u t r i t i o n , and  the  preventable  d i s e a s e s , and these  To  have c o n t r i b u t e d  Project a  viable,  Nevertheless,  as  refract  in —  dialectic  evident i n the  compelled  to  fulfill  in  the  not  the  poverty, malaria,  diarrhoeal a l l of  Saradidi Rural  Health,  own  jodongo,  way  evolution only the  the  development project.; (CHWs)  (VHsTH) who* b e c a u s e o f of t r o u b l e , "  problems,  and  t o make  H e a l t h Workers  times  the  problems,  nyamrerua,  i n their  Towards H e a l t h  most e x p l i c i t l y  the  Community  "immediate h e l p e r  is  water,  cholera,  self-sustained  i t i s the  V i l l a g e Helpers role  and  of  ameliorate  (SRHDP)  jabilo —  today  t h e endemic d i s e a s e o f  leaders  Development P r o j e c t  potable  illnesses  measles.  identifiable  community  experience,  of the  SRHDP.,  traditional  or  their  image  and  and  the  They  are  requirements  128 of t h e Luo nyamrerua, b u t a l s o torn  by t h e  yearnings  peripheral health  care  the  Family  Field  of  Health).  Health  While  economically  between" competing community  whole  community's service of  f o r salary workers  --  the c o l l e c t i v i t y .  3.2  are j u s t i f i e d  and  "betwixt  and  the  l a r g e r t r u t h s of the  by  any  number  these  It i s  understand  become a p o s s i b i l i t y  the Ministry  position  have g a t h e r e d  r e l e v a n c e t h a t I wish t o has  orders,  other  ( f o r example,  employed by  their  articulated  l e a d e r s --  status that  propensities  given  social  and  have e n j o y e d  Educators  these  rational  ( i n some i n s t a n c e s ) , . t h e y a r e  of  the  tendencies  in  this epistemological  i n determining  i n t h e L u o community  how  CBHC  of S a r a d i d i .  SETTING  3.2.1  Climate  Saradidi situated  Rural Health  Development  i n t h e two s u b - l o c a t i o n s  West, S i a y a forty  and E n v i r o n m e n t  District,  Project  (SRHDP)  o f Asembo E a s t  Nyanza P r o v i n c e .  It lies  i s  and Asembo  approximately  m i l e s west o f t h e town o f Kisumu a n d c a n be r e a c h e d  public transport divides  the  (bus o r m a t a t u )  two  Bondo-Kisumu r o a d  s  sub-locations down  from the g r a v e l road and  t o Asembo Bay on  extends  from  by  that the  L a k e V i c t o r i a (see  Figure 6). Asembo  Bay  trading centre are a  few d u k a s  was  previously a  operated  thriving  port  by I n d i a n m e r c h a n t s . •  (Kiswahili  f o r s m a l l shops)  t  town Today  a  and there  couple of  129  F i g u r e 6. S i t e o f 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 , S i a y a D i s t r i c t , Nyanza P r o v i n c e , Kenya  Adapted f r o m : The World Bank, Kenya: P o p u l a t i o n and Development ( W a s h i n g t o n , D.C.: Development Economics Department, E a s t A f r i c a C o u n t r y Programs Department, The W o r l d Bank, 1 9 8 0 ) , R e g i o n s and Districts  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 . visitors  to  Company."  This  merchant  Planning  to  Research  (IEF),  World  United  (ONICEF), T e a r  Nairobi lodge  position  (FPIA) ,  Neighbors, World  F u n d , and c i v i l  It  Lake,  Luo  because o f i t s from  Family  I n t e r n a t i o n a l Eye  African  Medical  Health  Organization.  and  Emergency  s e r v a n t s f r o m Kisumu and  Asembo Bay h a s t h e  track.  by t h e  wealthy  i s remote,  feeling  of being  beautiful  but i n appearance l i k e  in i t s  a ghost  town  has s e e n a l i v e l i e r d a y .  The  medical  students  from the U n i v e r s i t y o f  were i n v o l v e d i n t h e "community s t a y e d a t Lwak; the  business  cases,  " S i g a r and  International Children's  there.  the beaten  by a  Representatives  (AMREF),  Nations  stay a t  owned  a thriving  the P r o j e c t .  Foundation  (WHO),  that  i s  International Assistance  Foundation  off  Project w i l l  h o t e l which  has enjoyed  proximity  Fund  the S a r a d i d i  I n most  Project's  Hospital  i ti s  approximately  centre.  and a d j a c e n t  diagnosis"  There i s maternity  a Roman  there i s  a market of  twice-weekly  Ndori at  and S a r a d i d i .  these  herbs,  vegetables,  dukas  ( s m a l l shops)  matches, t e a , cooking  0M0  Lwak a n d  centres,  fresh  sell  other  [the detergent  o i l ( B l u e Band  margarine).  and a  girls  As i n Asembo Bay, i n the  surrounding  On t h e m a r k e t t h e Luo  meat, b r e a d ,  from  Catholic Mission  c e n t r e a t Lwak  s c h o o l r u n by t h e same m i s s i o n .  villages  f o r the P r o j e c t  7 k i l o m e t r e s away  secondary  centre at  6  N a i r o b i who  peasants  and d r i e d  household  days  held  can  buy  fish.  items  such  f o r washing c l o t h e s ) ,  The as and  131 Coming  from  Nairobi, and  and  feet  cool  the area around  humid.  heat  the  Proximity  humidity  (Nairobi)  are  and  the  road  helplessly  During  fully  i n v o l v e d i n the  the r a i n y It  on  the r o a d  and  dust.  planting  The  soil  is  o v e r - g r a z i n g , and  with  rains.  reflection p r e s s u r e and  grow  of  the  The  what t h e y  families  supplement  uncommon,  for  eat,  i n the their  a t the s i d e of its  passengers  necessary  but  women a r e  millet,  cassava*  area  harvest t h a t grow  subsistence  to feed  however,  their  due  to  e r o s i o n t h a t comes  to  crop  i n most c a s e s ,  sight  and  over-rutilization due  rains  roads  so a s  the s o i l  from  the  men  weak,  level  short rains i n  with  of  the l a n d i s a  the  population,  rotation.  subsistence agriculturalists  enough t o c a r r y them f r o m few  not  Both  l a n d shortage  d i s a l l o w s the  these  long  seasons  of maize,  over-planting,  main,  is  this  miles  the  and t h e  g r o u n d n u t s i n t h e sandy s o i l ,  heavy  a few  hot  5,280  above s e a  X e t , t h e r a i n s a r e a welcome  drought  families.  the  feet  b u s e s s w o l l e n i n r e d d i s h mud  s t a n d i n g by.  t o be  contributes to  seasons:  June  impassable.  months o f  p e a s , and  3,720  rainy  November.  after  large  two  or matatus s t u c k  around  d e c l i n e i n e l e v a t i o n from  H a r c h and  i n s t a n c e , t o see  i s experienced  Victoria  between  frequently  territory  factor i s i t s location  There a r e  roughly  October  t o Lake  to approximately  equator.,  occur  highland  Saradidi  as does a  ( S a r a d i d i ) . , another the  and  are  cum  to store  There are a  c o t t o n as a c a s h  activities,  the  pastoralists  unable  to harvest.  In  but  crop with  to an.  132 inadequate few  credit  marketing  i n c e n t i v e s to develop Generally  speaking,  Province are percent  very  of the  salaried  or  3.2.2  the  into  areas  an  has  next  people  receive  a  three  Health  areas  estimated  be  who  and  who  the  have  It  is  building  services  the  of  away.  The  i s thirty  is  transportation  clear a  are  through  Each  (SRHDP)  of these  15,000 p e r s o n s ,  To  date, i n the  themselves  is  three and  in  50,000.  there  are  household  into  Village  S a r a d i d i Dispensary  h e a l t h s e r v i c e s were  away f r o m  the S a r a d i d i  a government d i s p e n s a r y closest  kilometres that  serious and  the  nearest  at Ong'ielo,  quite  P r o j e c t area  (VHCs) .  seven k i l o m e t r e s  which  eleven  income  been i n t e r v i e w e d  which i s  kilometres  t h a t only  i t i s hoped t h a t a p p r o x i m a t e l y  basis,  and  (A,B,C) .  p o p u l a t i o n of  self-help  centre,  Hyanza  Development P r o j e c t  have o r g a n i z e d  H e a l t h Committees Before  area of  Heeds  i n v o l v e d i n the P r o j e c t .  15,000 p e o p l e surveys  regular  are  way.  in this  Saradidi  there  7  three years,  will  people  I t i s estimated  Saradidi Rural Health  organized  Siaya  Luo  poor.  P o p u l a t i o n and  The  infrastructure,  t h i s area i n t h i s  p o p u l a t i o n i n the  self-employment.  the  and  government from the  underutilization  problem  communication  that  on  a  a t Lwak Project thirteen  hospital i s  at  Project centre. 8  of  existing  is  exacerbated  by  problems.  There are  no  133 telephone  services  i l l n e s s cases, area in  and  with v e h i c l e s  or  ambulances  consequently, they  are  illness  experience  people  of t h i s  area.  when v i s i t o r s  serious  come t o  f r e q u e n t l y approached t o  is  an e v e r y d a y  a f f e c t s mainly who  children  are pregnant.  the  assist  y e a r s of age to ten  of  mortality  and  category;  morbidity  eighty  inadequate  water s u p p l y  unprotected,  and  during  spend  six  hours  up  Victoria  of t h i s  to  for  most  and  women  the dry season,  also  estimated causes  diseases five  m e a s l e s * f° an  years  integral  problems i s  t h e community.  Streams  the  remain,  women a r e known t o  walking  t o o b t a i n water f o r t h e i r  an  Other  9  and  u n d e r three,  under  these disease  a day  and  diarrhpeal  p e r c e n t of c h i l d r e n  most o f  of the  m a l n u t r i t i o n are  out  are  h a v e worm i n f e s t a t i o n s ) ,  f a c t o r determining  the  y e a r s o f age  percent are s e v e r e l y malnourished.  (approximately age  under f i v e  Forty percent of the c h i l d r e n  are i n t h i s  five  one  for  I t i s endemic t o t h e a r e a  U n d e r n u t r i t i o n and  s e r i o u s problems.  reality  Malaria i s probably  serious diseases experienced.  3-3  for  emergencies. The  of  available  to  and  from  Lake  households.  CONCEPTUALIZATION AND INITIATION OF HEALTH DEVELOPMENT PROJECT (SRHDP)"  THE  SARADIDI BUBAL]  T h i s i s a community p r o j e c t , not a c h u r c h p r o j e c t ! ( E x e c u t i v e C o m m i t t e e member, SRHDP) This Saradidi  section Rural  addresses Health  the i s s u e  Development  of  Project  origins  of  (SRHDP).  the To  134 begin, that of  I attempt  a reconstruction  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 .  e v e n t s w i l l be f o l l o w e d  process  that l e d  dispensary, Helpers  and  to  independent i n nature of  by a d i s c u s s i o n  the (i)  ( i i ) the  Towards H e a l t h  (VHsTH).  the i n f l u e n c e s  relations  As  I will  that  project,  and  building  chronicle  of the  conceptual  of the  self-help  and t o  orientations  of V i l l a g e  a Project  attempt  caused  o f events  This  subseguent t r a i n i n g  derivation,  community-based  of the ordering  to  that  i s  i s o l a t e the  i t t o be  an  uniquely  expose the e p i s t e m o l o g i c a l  that  have  affected  i t s  development.,  3*3.1  4 Skcaaicle o f £ £ 0 j e c i gvgatS  Most genesis a  of  of the P r o j e c t  number  Anglican  the people  of  elders  denomination  involved  in  t h e SRHDP  t o t h e church. i n the of  Dr.  Saradidi  the  Church  P.  trace  the  states  that  church  [an  Province  of  1 1  parish of the  Kenya) were prompted by t h e h e a l t h p r o b l e m s i n t h e a r e a and by t h e r e a l i z a t i o n t h a t t h e Government c o u l d n o t make its services universally a v a i l a b l e and a c c e s s i b l e to the majority o f the people of S a r a d i d i . 4 2  At the  that time,  p a r i s h community  This person (Chloroquin aid  the only  available health  was t h e work o f  would r e c e i v e  a  regular  tablets f o r malaria.  s u p p l i e s from  Mase.no S.outh.  care  service i n  the health  secretary.  supply  Aspirin,  of etc.),  t h e Development O f f i c e o f  These s u p p l i e s  would be g i v e n  basic  drugs  and f i r s t  t h e D i o c e s e of, on a l o a n  basis  135 and  reimbursed  persons persons  in who  resources community the  people  Even  then,  were  after  the  the health  parish  were o n l y  the  1 3  these  members  Unfortunately,  the  limited  care  of the  ( i . e . the Church of the Province i n the l a r g e r  community  the s e r v i c e s a v a i l a b l e  the drugs to  health  Saradidi  o f Kenya) and n o t  o f Asembo E a s t and B e s t . for this  community  to  members.  smaller  community  inadequate  service f a c i l i t y  experienced water s u p p l y ,  n e e d s . D r . P. f e l t  would  (PHC)  be an  the  i n t h e community,  focus  Care  intent  and the  way  of  something  health  prevalence of  the h e a l t h - r e l a t e d  H e a l t h Care  addressing  p r o b l e m s . , M. a n d S., two m e d i c a l  students  these  (CBHC),  community  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 o f t h e a r e a , s u p p o r t e d  in  this  Dr.  P.  recommendation.  In February  o f 1979,  S a r a d i d i CPK  elected  care  t h a t t h e method o f P r i m a r y  o r Community-Based  effective  on among  -- t h e problems  lack of a  Siven  absence  l e a d e r s were  on d o i n g  i n the area  were p r e v e n t a b l e .  Health  and c h u r c h  a n d were  diseases that of these  a two y e a r  the d i s c u s s i o n s going  The c l a n  concerns  about the problems an  to Saradidi after  he was a l e r t e d  voicing similar  the  church  inadequate.  overseas,  of  community.  b e n e f i t e d most f r o m  Hhen D r . P. r e t u r n e d  the  secretary sold  church  members t o a t a s k  Committee.  The  the 1 4  R u r a l D e v e l o p m e n t Committee i n acted  group  on t h i s  suggestion  t h a t was c a l l e d  f u n c t i o n of the  and  the Interim  I n t e r i m Committee  was t o  136 "create of  awareness"  community-based  period,  church  persuaded  to  area:  health  care  and  involved could  the  involved  d e s i r e to get  increase to the that  the  gala  i t  in  standard moro  was  (Luo  futile  assistance.  of for to  the  I f anything  would have  t o be  care  services,  and  i n the  the  area.,  and  through  clinic better  or  and  projects  I t was  to  evident  p u b l i c at large),  government  constructive  done by  a  the  communication,  community  wait f o r  programme.  accessible  i n income-generating  living  were,  e s s e n t i a l needs of  w a t e r , an  transportation  month  alike  community  the  notion  A f t e r a three  this  comprehensive h e a l t h of  to the  n o n - c h u r c h members  potable  developed system  membership  (CBHC).  a g r e e on  c l e a n sources of  delivering  church  members and get  Everyone f e l t  i n the  1 5  was  to  t o be  the  provide  done,  efforts  i t  of  the  community. After Interim  these i n i t i a l  Committee c o n t i n u e d  Project.,  With the  assent  a g r e e d upon  at  gathering  meeting)  piece  or  of l a n d  the  on  would a c t  as a  Towards H e a l t h Project.,  the  with the of the  task  of  t h e y began  behind  (Kistfahili t o look  Saradidi  organizing  community  p u b l i c baraza —  members o f t h e  for  the  Saradidi c l i n i c  referral (VHsTH)  facility  and  a place  (see  f o r the  the  them a  —  public  for a suitable  w h i c h t o b u i l d a permanent s t r u c t u r e . ,  s t r u c t u r e w o u l d be  the  efforts,  Figure Village  t o keep t h e  7)  This and  Helpers  records  for  137 Figure Saradidi  Two  7. Clinic  photographs o f the p a r t i a l l y  on the s i t e o f the S a r a d i d i Rural  constructed Health  h e a l t h care  Development  clinic  Project.  138 In conjunction  with  the  c l a n e l d e r s i n the  I n t e r i m Committee d e c i d e d  on  the  fir.  community a t  together  with  large.  a number o f  p i e c e of l a n d f o r t h i s site  a  a suitable S.,  other  purpose.  The  t o the  programme  was  to  involve  s u b - l o c a t i o n s o f asembo E a s t and the  people  i n the  vicinity  or  P.,  donated  d e c i s i o n to b u i l d  the church  a l l of  o f Dr.  farmers  P r o j e c t ' s development. the  the  appropriate for  the f a t h e r  peasant  c o n s i d e r a b l e d i s t a n c e from  critical  site  community,  on  compound  By  design,  people  and  members o f t h e  a was  the  i n the  asembo .Best,  a  two  not  only  Saradidi  CPK  church. at  one  East  {who  of the i s  first  public  barazas,  c u r r e n t l y the  H e a l t h Development P r o j e c t )  of  began t h e  Asembq  the  Saradidi  Rural  fund-raising drive for  {in  Canadian c u r r e n c y ,  approximately  $3.00)..  the  people  at the  donated  Kenya s h i l l i n g s for  the  building  to begin  construction was  the  p o l e s aud  their  actual  construction  of  baraza  the  and  the  urban c e n t r e s  timber,  iron  of  Kenya)  sheets,  {Kiswahili f o r l o c a l  and  1 6  On  the  payment  c o n t r a c t o r or b u i l d e r ) .  of  with and  work  in  the  chapters worked i n  cement, for  600  donated  effort  lived the  day,  dispensary  Villagers  building,  donating  that  scheduled  cooperative  who  shillings  a total  The  organized.,  time  Kenya  mud-and-*wattle  {comprised o f r e s i d e n t s of the a r e a the  twenty  building.  of  subsequently  sapling  giving  of  self-help  gathered  by  chief  the  who  dispensary  Patron  the  the  nails, f undyj  139 Before construction, h a v i n g by Saradidi  however,  t h i s time e s t a b l i s h e d CPK  church  and  its  identified  "villages"  Project.  Traditionally,  "village"  in  however,  the  groups  of  members o f  contiguous have  members o f  this larger  core  considered the  referred  "village"  patrilineage. territorial  — to  the as  land the  on  the  of h i l l s ,  homesteads are Once i d e n t i f i e d ,  the  Luo,  for  shambas  dhoot  live  and  along  Committee  which r e p l a c e d  the Interim  and  Committee were r e - e l e c t e d  Secretary to  the  the  can  be  ( i n Luo)  of  when  the being  farm —  i t is  sense,  the  length  to  of  Project  the of  a of  to e l e c t t h e i r  R e p r e s e n t a t i v e s from joined  Treasurer,  to  side.  Committee then  Chairman,  The  ( K i s w a h i l i f o r gardens)  V i l l a g e Health (PC)  ;  is  a physical  v a l l e y s to each  (VHC).  whpse  they  " v i l l a g e s " were a s k e d  V i l l a g e H e a l t h £omgittee  identified  1  dhoot  a  Project,^  together. *  the  situated  as  t h e i r descent  or  —• the  dala)  sense,  clan  In  8  are  i n the the  this  which t h e y  gwenq.*  and  Committee  trace  the  in  the  Alternatively,  unit  homesteads o f a " v i l l a g e " ridge  In  of  belonging  —  Committee  such t h i n g  purposes  {in  from  together  no  Interim  a segmental d i v i s o n ,  localized,  is  ; the  " f e e l i n g of  autonomy  work  homesteads  patrilineage. ,  maximal  considered  a  there  the  Committee  Development  could  For  7  Interim  i t s own  fiural  that  Luoland. *  occupants  same  the  form  the  the  Project,  Committee. original  Committee.  each  The  Interim  140 The  Project  leadership of  was  just  1979.  M,  Primary School,  was  additional  who  The  Project  of  the  Health  i n the  be  the  the  Figure  for a  schematic  s t a g e s of the few  the  their people  At  i n order  own  (AMREF), Nairobi),  and  Emergency Fund felt-needs  too  the  to the  0.  for  from a l l  large  Project.  to  be  If  was  from  the  Committee. full  the  of the  This  representative  but' w o u l d of  the  Committee.  representatives  affairs  the  workshop, t h e  Department o f United  (UNICEF),  through  the  the  They  9  African  the  Saradidi  h e l d f o r the  of p r i o r i t y  the  the  was  this  "villages.'?*  from  was  diagramme  after  a seminar  Project.  to l i s t  October  have  the  programme  (see  organizational  Project) .  months  constructed,  everyday  able  Saradidi  representation  Committee)  to run  the  Executive  the E x e c u t i v e  responsible  Project  in  of l e a d e r s h i p  of the  to elect  authority  A  pattern  management o f  t o form  died  the  a n o t h e r h e a d m s t e r , a Mr.  Committees,  everyday  would  (i.e.  8  by  Committee, w i t h i t s f u l l  P r o j e c t Committee  body  when he  headmaster i n  selection  therefore,  Committee  M,  a  change i n the  Village  decided,  was  replaced  P r o j e c t came w i t h t h e  effective  momentum t h r o u g h  o f i t s C h a i r m a n . Mr. Mr.  An  gaining  dispensary  community  leaders  concerns that  and  Community  t h e y had  Nations how  of  CBHC.  in  for  resource  Foundation  (University  International  to e f f e c t i v e l y  structure  by  Research Health  leaders  were i n s t r u c t e d  were t h e n a d v i s e d  Medical  was  of  Children's  address  these  Subsequent  tq  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 t h e 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  E x e c u t i v e Committee (EC) V i l l a g e Helpers 3 S  P r o j e c t Committee (PC)  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 ( I C )  1 R u r a l 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 t h e P r o j e c t a r e numbered i n t h e sequence o f t h e i r d e v e l o p m e n t  142 this  workshop,  full-time,  the  salaried  £EQject lanaqer, iatchman.  the  Committee  workers f o r  Community  The  first  W o r k e r s were t r a i n e d and  Project  Saradidi  the  elected  Saradidi  fiurse,  Centre:  Community  (named V i l l a g e H e l p e r s T o w a r d s was  unofficially  a  Srpundsffla.n.  group of volunteers  Centre  five,  and  Health  Health),  opened i n August  of  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 H e a l t h D e v e l o p m e n t P r o j e c t [SBHDP)  3-3-2.1 It the  "Community" o v e r  i s evident origins  discussions and  from  of  the  between  subsequently,  Dr.  preceding  Project  (i)  clan  i n more  can and  chronicle be  specific  regarding  a community-based  the  of the  deliberate abrogation  the  church)  the  Project  and  of  to the  construction  part clan"  of and  of  Project  collective  individual,  this  and  the  the SfiHDP,  leaders  involve  s u c e s s f u l has  these  the  effort  family  the  themselves, with [ i i ) the  arose  in  time progressed, t h e r e  was  specific  in  conceptual i t  origins the  [i.e.  o r i g i n s of  I f there  is  process involved  i s the  t o "break the  been  to  programme  "community."  people i n a  that  Initially,  a c o n s c i o u s attempt t o t r a c e  theme t h a t c h a r a c t e r i z e s the  as  attributed  consultations  discussions  c h u r c h , but  of events  church leaders  medical students.  context  the  Sural  "Church"  two  a  P and  the  Saradidi  commitment  ties  of  differences, that  the  church  and  clan,  many o f  in  on  "community" e f f o r t .  i n overcoming  one  the  So  church, current  143 representatives or  current  community say. this  on  the  association  project,  No  one  leaders  i n the  3.3-2.2  Two  Project. Luo,  leaders  within  "professional"  leadership  and  life;  involved  Saradidi Sural played  combined  the  has  whose  are  i n the  the  leader.  The  Towards  Health)  this  clan-based  and  2 1  Both  of  part.,  The  is  currently  case  making o f  the  Community H e a l t h bridge  innovative  and  and  ameliorative  {in  "generational" are  the  derived  from  Luo  initiation  of  the  groups  of  both  authority  symbolize  and the  order.  that  has  cooperative,  type of  [or  their  authentically  of t h i s  traditional  of  in  SRHDP an  Workers  social  leaders  I t i s a merging of  result  a the  structures  Project*  and  the  stage  operative  e m e r g e n c e of a t h i r d  structures,  combined  of  there  authority  intentions,  authority  of  initial  r e s t s on  Development  a significant  seen  honour f o r  conceptualization  authority  "community-based" P r o j e c t . effort  a  repeatedly  the  community  considerations.  Health  to the  i n the  lineage,  interests,  contributed  at  traditional,  authority and  they  is  itself.  emerges  leaders 2 2  "This  i s given the  original  Leaders  the  "socio-economic"  church.  or group  Saradidi  whose  2 0  the  rather,  there  There are  status  leaders  of  Types of  jodongo)  social  but  area  Committee deny any  a church p r o j e c t , "  individual  Nevertheless, of  with  not  c r e a t i v e urge,  typology  Executive  community  Village  Helpers  professional c r e a t i o n of  an  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  Since  there  between  types  of  experience minority  to a of  of  community Ministry  of Health  majority  of  would: n e v e r government  continue to the forced  other the eyes  i t s own  leaders believed  to stay  the  opinion  harambee  hand,  the Health  preferred that i t  of i t s  and f o r t h i s  government  health.care  reason,  on t h e i r  own.  with would  resources  they 2 3  the could  The view o f l e a d e r s  was t h a t t h e  manage t h e p r o b l e m  salaries,  M i n i s t r y of  P r o j e c t so  the  t h e Project»s  other  they  A  i f the  f o r financing  affair.  the bulk  i . e . , the  dispensary,  On t h e  the  stated*  that  take over  In fact,  out of  be  ineffectiveness.  that the  perspective,  would be  Fortunately,  had t h e e x p e r t i s e and commitment o f D r . P a n d t h e  two m e d i c a l  accomplishment of  and  t h e SBHDP o c c u r r e d  reality;  and  and r e s p o n s i b i l i t y  urban areas,  s i n c e they  of  get i n v o l v e d .  should  developing  would e v e n t u a l l y  to allocate  to  It  maintenance c o s t s .  political  cooperation  [traditional  political  were  a l w a y s r e m a i n a community this  CHWs.  government i n a c t i o n  constructed  and  and  leaders  of  larger,  leaders  administration drugs,  involving  that the process  response  involvement  t h e o p p o r t u n i t y was g i v e n f o r t h e c r e a t i o n o f  CBHC programme  however, in  this  both  professional), a  exists  Projects  community  government-inspired  students, of this  t h e r e would be  goal.  leaders  —  no b a r r i e r s t o  I t would r e m a i n —  i n the  a  not  community  [harambee) p r o j e c t .  and  a  145 Nevertheless, meeting), familiar  the  during  actual a c t i v i t i e s  harambee e v e n t  t r a d i t i o n a l Luo they  boast)  the f u n d - r a i s i n g  but with the a d d i t i o n a l  of referring  between r i v a l l i n e a g e g r o u p s . specifically building  called  for  of the c l i n i c , t h e two  Asembo  Sums  Iqisungore) of  a few  seized  between  The idea by  of  this  baraza  of  s u b - l o c a t i o n s of  o f money these  people  which  was  for  the  money  two  Asembo E a s t  were  raised  rival  groups  Asembo  As a m o d e l f o r  o f "unmet f e l t  partisan  and  community  tended  them  their  in  of  health  symbolized  transcended c l a n ,  These  to the competitive display  raising  "community-based  which  development.  it  for  and  competitively over  the  span,  Need f o r C l i n i c a l S e r v i c e s  the  eventuality  range  (Luo  of  hours.  3.3.2.4 The  2 4  the  t h e C h a i r m a n o f t h e SBHDP c r e a t e d a  c o n t e s t between West.  of  element  Sisungore  During  the  (public  were c h a r a c t e r i s t i c  competitive r i v a l r y ,  i s a way  baraza  to  sectarian fragment  ability  to  East new  and  (CBHC) West  as  addressed  a  also legitimized  and  was  possibilities  change t h a t  n e e d s , " i t was church,  care"  government  associations community  in  for broad  i n that  interests. in  the  members and  cooperate  an  Luo. deter  development  programmes. Yet from could  agree  the on  very b e g i n n i n g , everyone the need  for  a clinic.  i n the Project T h i s was  area their  146 primary  incentive  involvement  Before V i l l a g e  be  trained  prevention have  to  and be  services. their  2 5  to  built The  focus  Health  Helpers of  offered  of  have  what and  other  the P r o j e c t attain  Project (VHsTH)  communicating a  clinical  disease  clinic  would  health  care  clinic  would  the  symbolized  o f f e r and  modern  their  health  p e o p l e i n the D i s t r i c t  THE SOCIAL ORGANIZATION OF THE DEVELOPMENT PROJECT (SRHDP)  their  Towards H e a l t h  p r o m o t i o n knowledge, that  for  Development  b u i l d i n g of the S a r a d i d i  conveniences that  3.4  symbolic  f o r purposes  health  perception  desire  the  i n the S a r a d i d i Rural  (SRHDP). could  and  care  enjoyed.  2 6  SARADIDI RURAL HEALTH  The work was s t a r t e d , by t h e 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 w o r k e r s a r e p a i d f o r , by t h e • community; The l a n d was g i v e n , fey. t h e community ! (Treasurer, From t h e d i s c u s s i o n and  organization  that  the  recognized  and  of events that  o f t h e SRHDP  Project  itself  need i n t h e  Executive  was c r e a t e d  proximate s e r v i c e s  to the  and  there  It  was  services  was no ambulance decided  that  9) , in  i t i s evident response  to  a  area. felt,  Hospital  SRHDP).;  l e d to t h e development  (see F i g u r e  The g o v e r n m e n t , i t was  nearest  Committee,  in  was  not p r o v i d i n g e f f e c t i v e  people  were a t S i a y a  i n Saradidi. [30  kilometres  s e r v i c e t o handle c r i t i c a l order  to address  these  The away), cases. serious  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 t h e 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 External Organizations  Department o f Community H e a l t h , University of Nairobi  S a r a d i d i Rural H e a l t h Development P r o j e c t  Project Director  Funding Agencies (eg. FPIA)  M i n i s t r y of Health and Non-Government Organizations  Project Manager  Community Nurse  Volunteer Volunteer Organization  Executive  Committee  P r o j e c t Committee  V i l l a g e Health Committees  V i l l a g e Helpers towards Health (VHsTH) •  Villages A s c h e m a t i c diagramme o f t h e 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 t h e SRHDP w h i c h i n d i c a t e s t h e 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 t h e P r o j e c t .  148 p r o b l e m s , a CBHC programme would be i n i t i a t e d . , t h e agreement  (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  area  (the p h y s i c i a n ,  medical students,  teachers,  and b u s i n e s s m e n ) .  Director  (Dr.  programme t h a t  P)  hoped  opinion  of  adamant  in their  curative  services.  build along very of  f o r the  the majority  household desire  a self-help  heads to  of l e a d e r s  of a  (representing  their villages)  construct  on  the  a clinic  Project  the Project  were  providing  Director  Committee.  e v i d e n c e was g i v e n  while  went  From t h e  of the a b i l i t y  t o cooperate i n the  t h e d i v i s i o n s between  o r i e n t a t i o n s posed  introduction  c u r a t i v e and  p o t e n t i a l development  of income-generating  H e l p e r s Towards  interest  CBHC  and h e a l t h  a d d i t i o n a l s t r a i n s were b e g i n n i n g t o s u r f a c e  position  Project  of the P r o j e c t .  preventive  the  Health  tensions  groups  (VHsTH)  bore  the  I t centred  those  who a r e  persons  capacities in  projects.  The  who i n c o r p o r a t e d  between t r a d i t i o n a l  difficulties.  various  prevention  and p r o f e s s i o n a l l e a d e r s  Nevertheless,  lems,  development  in  dispensary,  beginning, therefore,  development  headmasters,  Because o f t h i s o v e r r i d i n g consensus t o  with t h e l e a d e r s  traditional  leaders  W h i l e t h e newly e l e c t e d  would e m p h a s i z e d i s e a s e  promotion a c t i v i t i e s , the  by community  was i n  principle  the  established  This  brunt  selected the Project  and  these  o f money.  elected  work  with the Village i n their  and p r o f e s s i o n a l  of  on t h e p r o b l e m  prob-  to  emerging Should work  as v o l u n t e e r s  in or  149 should  they r e c e i v e  threatened members  (SRHDP), t h i s  i s s u e was  while these  t o day  activities  force  to  Executive (VHCs),  Project,  Development  there and  goals,  was  and  under  objectives.  of  the  In  structure  these  f o l l o w i n g i n d i v i d u a l s and  Director  order.  t h e canopy  construction  the Project  compelling  political,  the  the  a  t h e day  communal  on t h e o r g a n i z a t i o n a l  (EC),  Project  serious.  religious,  subsumed  SRHDP  and of this that  and  the  groups:  the  V i l l a g e Health  [BD) ,  that  o f community  were c h a r a c t e r i s t i c o f  i n t e r e s t s were  Committee  Towards H e a l t h  Health  lineage,  interests,  in  involvement  collective  individual,  experience of  3.4 . t  i n the  I concentrate  developed  a l l the issues  p o t e n t i a l l y t h e most  tensions  accomplish  professional  section,  Of  Saradidi Sural  Yet  community  salary?  t o c r i p p l e the s u s t a i n e d  i n the  Personal,  a  Committees  and t h e V i l l a g e H e l p e r s  (VHsTH).  The E x e c u t i v e  Committee  (EC)  I t i s n o t i n o u r own i n t e r e s t s t o r e l y on g r o u p s , parties, o r i n d i v i d u a l s who may w i t h d r a w their s u p p o r t o r who may d i e . ( C h a i r m a n , E x e c u t i v e C o m m i t t e e , SRHDP).  3.4.J.1  D e s c r i p t i o n and F u n c t i o n C o m m i t t e e (EC)  There are c u r r e n t l y Executive functions  Committee as  eighteen [see  of the  Executive  i n d i v i d u a l s who  Figure  10).  This  s i t on t h e committee  Figure  150  10.  Members o f E x e c u t i v e Committee (EC)  A photograph o f some o f the members o f the E x e c u t i v e Committee (EC) o f the SRHDP c o n f e r r i n g with the P r o j e c t with Dr. Roy S h a f f e r  Director  (on the l e f t ) and  (second from the r i g h t ) o f the Community  Health Worker Support U n i t  (CHW-SU, i n the A f r i c a n Medical and  Research Foundation) on the P r o j e c t  site.  151 the of  administrative the  §oro  Project,  the  and  (Luo f o r t h e  reiterate  the  village  in  this capacity,  general  meeting  process  Committee,  in  the  formed (VHC)  which  needs i n  their  Helpers  Towards  was  area.  VHC  of  Committees  (VHCs) c o n s t i t u t e t h e  represents  the  a  of  group  Committee. As  was  everyone  gala  the  moro  (the  ninety-six  indicated, together the  the P r o j e c t .  Executive  villages  gillage  Health  selected  the  Villagq  initiated  an  b a s e d on  the  area.  The  top  Village  meeting).  individuals  of  Each  village  general  briefly  formation  P r o j e c t Committee  on  four  Health.  (PC)  This the  and totals  Project  from  and  the  burdensome a p r o c e s s Project  d e c i s i o n s that are It  was (EC)  decided, to  Committee made on  were e l e c t e d  t o a c t as  Vice Secretary,  nine  members were added a s  a  manage  Chairman,  Treasurer,  call reach basis  to e l e c t  an  financial, Project.  Vice  and  w e l l as  to  the  of the  to  daily  therefore,  administrative affairs  Secretary, other  To  ;  gala  identifying  twenty-four  i t i s too  Committee  supervisory, officials  of  the  2 7  c o n s e n s u s on for  each  affairs  study.  and  i n the  officials  for  i n turn  their  resources  my  to a  (VHsTH)  project i n  financial  time o f  responsible  Health  income-generating  or community).  members  Each  represents  were t w e n t y - f o u r  a t the  elected  everyday  that l e d to the  there  SBHDP  and  Committee  available  s t e e r i n g body i n the  political  Executive  registered  and  Vice  three  Six  Chairman, Treasurer;; ex  officio  152 members  (the c h i e f s a n d s u b - c h i e f s )  Seventeen  members  schoolteacher of  a retired  civil  and  church  the  only  (Luo f o r f i r s t  servant.  t h i s composition,  Executive  men,  and t h e mikayi  schoolteachers, In  are  which t o t a l l e d  The men  t h e y combine  Committee  that  are  i s a  or senior  wife),  headmasters,,  and c l a n  authority based  woman  are  e l d e r s , l a y readers,  eighteen.  elders.  s y s t e m s on t h e  on  descent  t r a d i t i o n a l heads o f l i n e a g e s  and e l d e r s ,  as p r o f e s s i o n a l i s m  h e a d m a s t e r s , and d o c t o r s ) .  3.4.1.2 All  [teachers,  as well  The E x p e r i e n c e o f E x e c u t i v e C o m m i t t e e Members i n t h e 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 of  residents  the  leaders  of the area.  on  the  They  live  Committee  are  and work-in t h e v i c i n i t y  unlike  h a v e moved t o  t h e urban a r e a s f o r reasons  a r e committed  some o f  Executive  of Saradidi —  and  jodongo)  (the  t h e men from  t o t h e development  the d i s t r i c t  who  o f employment  of the place  —  and i t s  people. When t h e d i s c u s s i o n of  the  SRHDP a s  i n the area  a means  turned  t o address  t o t h e forma.tioi\  some o f  p r o b l e m s o f w a t e r , unemployment, and h e a l t h the  leaders  thought very  f o l l o w i n implementing  carefully  their  on:  that  as t h e p l a t f o r m  on  programmes  excluded  that  t h o s e harambee  services,  on t h e method t h e y  programmes i n  f o r an a s p i r i n g  were d e p e n d e n t  the p o p u l a t i o n  care  2 8  would  P r o j e c t ' s a i m s and o b j e c t i v e s .  They r e f l e c t e d were u s e d  the c r i t i c a l  on  o f non-adherents  the  t h e area  politician;  church  [as i n  Lwak,  which and  153 the  Diocese  o f Maseno  and  on those  programmes t h a t  implemented cultural  South  by e x p a t r i a t e s  aural  were d e s i g n e d , who o f t e n  c o n s t r a i n t s o f t h e Luo  avenues  for  community  organizational church,  or  community  structure  aid/donor  is  imposed  organization)  the  leaders  reason,  there  was  a conscious  Saradidi  Rural  Health  other leaders  emphasized  socialism."2«  Part  This action  on  i s the  the Executive  organizations. Executive  fact  Committee  the  attempt  i n the  would  government,  t o avoid.  " i n the have  i nthe  for  that  to construct  the  {SRHDP)  as  a s i n many area, spirit t o be  an  of the  the  Project  of  African  accomplished  "hands o f f " a p p r o a c h t o community  that  Committee In  by  the  o f government o r c h u r c h .  and p a r c e l o f t h i s  development  {whether  programme.  action  without the i n f l u e n c e  E a c h one o f t h e s e  Development P r o j e c t  programmes  and  appreciate the  posed p r o b l e m s  wanted  community-based  development  do n o t  people.  Programme);  initiated,  development  that  independent  Development  the  t h e community  are  suspicious  words  {a man  of  who  i s  the  leaders of these  who s i t external  Chairman  of  t h e headmaster  the  of  a  Primary School i n the area), I t i s n o t i n o u r own i n t e r e s t s t o r e l y on g r o u p s , parties, o r i n d i v i d u a l s who may withdraw their s u p p o r t , o r who may d i e . It  would seem  it  i s important,  their  that i n the eyes of i f not crucial  own u n i q u e and a u t h e n t i c  t h e s e community  to fashion  ways..  leaders,  t h e P r o j e c t in.  In retrospect,  they  154 are  particularly  able of  p r o u d and p r o t e c t i v e o f what  to accomplish  the  Treasurer  as a  community.  of the  headmaster o f a l o c a l  To r e i t e r a t e  Executive  Primary  they  Committee  have been the  boast  (an a s s i s t a n t  School),  The work was s t a r t e d , by t h e community; The p r o j e c t i s b e i n g c a r r i e d , by t h e community; The w o r k e r s a r e p a i d f o r , 2Y. community; The l a n d was g i v e n , fey. t h e While i n Project  community, !  reality  the  great  are volunteers  and n o t  s t a t e m e n t by t h e T r e a s u r e r Committee members the  Project.  Committee  income-rgenerating drugs,  appropriate mediator Executive leaders  these  projects,  the  of  this  Executive,  a d m i n i s t r a t i o n of the  Executive  (FPIA).  3 0  The  funds f o r the P r o j e c t  Family Project through  funds f o r the i n i t i a t i o n of eguipment  funding  i n administering  i n the  c o n t r i b u t e d by  demonstrations.  and  tenor  that  p r o f e s s i o n a l h e a l t h care  Committee  community.  the monies  t o acguire  technology  between  the  i n the  Assistance  negotiated  h a s been a b l e  have  from funds  International  D i r e c t o r , who  clinic,  they  was  paid,  of workers  d e m o n s t r a t e s t h e power  Initially,  disbursed  Planning  FPIA,  feel  majority  has these  for  the  assistance, He h a s a c t e d  organization(s) defended monies  Saradidi  their  and ability  on b e h a l f  of  and as a the as the  155 3.4.1.3 In  The  the  Initiation  early  o f Income G e n e r a t i n g  p h a s e s of  Project Director  (Dr.  and  SRHDP:  aims f o r the  P)  the P r o j e c t ' s  proposed  Projects  development,  these f o l l o w i n g  the  objectives  (i) ... t o i m p r o v e m e a s u r a b l y t h e h e a l t h s t a t u s o f the S a r a d i d i community by o r g a n i z i n g the community in such a way that they would take a major responsibility in and participate in the improvement o f t h e s t a t e o f t h e i r own health. 3 1  (ii) ... to improve the g u a l i t y of l i f e of the Saradidi community through a community-based health service system based on community participation. 3 2  As  a medical doctor,  s t a t u s of to  the  those  P focused  people i n the  address the  vulnerable  Dr.  area.  preventive  groups i n  c h i l d r e n i n the  the  on He  improving felt  health. care  community who  i t was  needs  community:  the  necessary  of the  pregnant are  health  most  women  under f i v e  and  years  of  age. It  i s i n t e r e s t i n g to  o f members  on  and  out  single  initiation  of  the  notice,  Executive  their  role  the  Project's  "improvement  of  the  elected my  w o u l d be  Committee a v o i d i n the  Project  state  given  leadership of  t o the  mentioned  with  repeatedly  Committee was  Executive that  to: ...  majority  this  emphasis  i n terms  the  fact  the  on  the  to focus health,"  (VHsTH).  role  of  supervision  Committee  their  r a i s e to a c e r t a i n standard  own  work and  the  If in  was  their  V i l l a g e H e l p e r s Towards H e a l t h  interviews  that  income-generating projects.  consensus of  attention  however,  on  of  Instead,  members, the  more the in they  Executive  156 t o t e a c h community and t o i n i t i a t e projects. This  shift  that  i s attributed  change i n the  members how t o make money ...  and  a d v i s e on  i n perspective i s  markedly e v i d e n t i n  t o the P r o j e c t .  the l a b e l  of  "Saradidi Rural Health  Project" to  " 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 . "  concerned,  the  administrative  Executive  body  well as  the  p r o p o s a l with a viability  in that Committee  introduced advised  to  proverb  certain  village  the with  as "seed  an  the  with  that sanctions  {VHCs) a s After project  an assessment of  resources that are a v a i l a b l e credit  money t o  money" f o r  the  begin. the  Village This  villages.  Health  money They  {EC) members t o " s t a r t  the gardening  a more c a p i t a l - i n t e n s i v e  the  EC r e c e i v e s  projects.  {based on  are  as  income-generating  EC w i l l  by E x e c u t i v e Committee  perhaps beginning  The  of v i l l a g e  of  j u d g i n g from  {VHC)  acts  t h e V i l l a g e H e a l t h Committees  merits  village),  themselves  (EC)  projects.  requests f o r funding  discussing  projects  Committee  f o r these  monthly r e p o r t s from  up  t h e name  T h e r e h a s been a s u b t l e  As f a r a s t h e i n c o m e - g e n e r a t i n g  its  income-generating  is are  small"  o f c a b b a g e s and moving  carpentry  project.  the advice t o "begin  small," states  that: I f you t r a v e l with a l i g h t l o a d , you w i l l r e a c h s h e l t e r more q u i c k l y when i t s t a r t s t o r a i n ... {atonga mayot ema iyombogo  A Luo  koth)  157 In  o t h e r words,  d e v e l o p i n g an resolve  not  There  and  members i n  too  a  the  to  to  date:  g r a n t s f o r these (approximately  projects $9.00  carpentry,  (approximately  This discussion  of  E x e c u t i v e Committee underlying  organization  the  carry  the  the  easier  to  confidence  initial  the  of  investment  of They  Project  by  to  and  of  project  One  the  political were  and  problems t h a t  The  shillings Kenya  and  experience  of  the  construct  administrative  And  has  o b v i o u s dependence on:  i n the  resources of  the  project  process  external  initial  the  (EC)  autonomy  i n t e n t i o n to, unite  together  of c o n s t r u c t i o n  (i)  the  Committee  adamant i n t h e i r  of  e x p o s e s some  have s h a p e d  Executive  community.  yet,  vegetable  hundred  t h e m s e l v e s ; i n o t h e r words, t o and  raising,,  making.  Kenya  two  role, function,  whole  professional  mat  that,  Issues  a collective  b e e n an  projects  poultry  range from s i x t y  SRHDP.  concerns issue  and  members i n t h e  issues  Project. the  i t is  $28.00 C a n a d i a n ) .  (EC)  of  organizational  in  of  g a r d e n and  knitting,  Canadian)  Epistemological  h i n g e d on  process  the  sheep r e a r i n g ,  marketing, weaving, p o t t e r y ,  the  the  income-generating  l a t r i n e coyer construction,  of  sustain  p r o j e c t i f the  number o f  have been a p p r o v e d  3.4.1.4  in  large. are  shillings  arise  income-generating project,  difficulties  community is  when d i f f i c u l t i e s  as  and  a  there  financial  organizations,  as  and (ii)<  158 the  Project  As  far  D i r e c t o r f o r the  as  concerned, argue  the the  EC  for  has  successful  in i t s  expectations  these  community.  aims  The  body, t h e r e f o r e ,  expressed i n  the  orientation Part  These  economically  in  and  the  Executive  care  and  potentially involved  the  benefit day  that  to  day  (PD).  CBHC s t r a t e g y This  of  fixation  care  on  of  this  services. of  an  Saradidi.^  the  Saradidi  clinic  workers  (the  Furthermore, of  a  orientation  experience  Groundsman*  affairs  As  (EC)*  income-generating  them.  (EC),  Committee  of  salaried  Nurse, C l e r k ,  way  i n the  existence  the  difficulty  i n f r a s t r u c t u r e at Executive  the  Committee  health the  in  venture.  association  (curative)  service  that  the  been  representative  Committee's  d e r i v e s from  sustains  same  leaders  Executive  promotion.  the  have  degree o f  emphasized the  health  projects  Manager, Community  a  of  professionally-oriented  members p e r c e i v e  of the  been  P has  tension  health  respects,  elected Project Director  with c l i n i c a l  of t h i s  emerging  own  the  income-generating  most  a collective,  has  to  construction,,  been s u c c e s s f u l i n t h i s  Dr.  with  as  are  ability  organizations  objectives  relationship  prevention  in In  external  there  medical doctor,  collides  control.  and  has  members w i t h t h e i r  disease  been  community  Nevertheless,  support..  organizations  and  the  this  aid/donor  self-determination  of  of  external  administration,  s h a p e d by  negotiation  and  Project Watchman)^  projects  might  s i n c e they  managing t h e  are  Project  159 —  which i n v o l v e s  workers — By  the  they f e e l  concentrating  in  leadership  of  feel  benefit  personal,  ranks of  the  the  well.  successful  that  from the  as  they  may  income r a i s e d decide out  as  of  a  the  3 3  the  original  i n most c a s e s in  development they  salaried  income  f o r themselves  T h i s e m p h a s i s on  leaders  d e s e r v e an  above  allocate salaries  funds.  yet,  the  for instance,  Project's  with  of  They c o u l d ,  to  and  the  (as i n d i v i d u a l s )  Committee  tension  they  projects,  these projects.  the  that on  income-generating eventually  supervision  Project's  s e l f - s e r v i n g i n t e r e s t s within, Executive  e m p h a s i s on i t is  the  Committee the  (EC)  is in  community  whole,  professionally-oriented  administration  who  display  these  concerns. I  turn  now  V i l l a g e Health to the they  to the  Committees  exigencies have  that  and  exercised  predominance o f over  of  experience of r e p r e s e n t a t i v e s  the  the  (VHCs).  verities a  i n t e r e s t s of  leaders  voice  morality any  one  of  village  life, the  Luo  community  life,  person or  on  (VHC).  Committee  closer  asserting  (nyamrerua)  V i l l a g e Health  are  the  in  V i l l a g e H e l p e r s Towards H e a l t h the  who  of t r a d i t i o n a l ,  powerful  e t h i c and  as  on  are  group. ,  The  represented  160 3.4.2  The  Village  H e a l t h Committees  (VHCs)  The V i l l a g e H e l p e r s Towards H e a l t h (nyamrerua) is a " h e l p e r " who s e r v e s and comes t o the rescue of people. (a V i l l a g e H e a l t h Committee l e a d e r , SBHDP).  3.4.2.1  D e s c r i p t i o n and Committee  The  o r g a n i z a t i o n and  Committees aspects  As  was  e l d e r s £jodongo)  I n t e r i m Committee. se i n Luoland.  (dala.  i n Luo)  through  the  core  eponymous  whose  ancestor  patrilineage  of  Whereas members descent  in this  their  daily  dhoof  (Luo f o r  by  clan-based  related  Village leaders  "village" homesteads other  group s i g n i f i e s the segmentary  branch  a  Luo  wife  different  folklore,  of  the  those wives  ( i n Luo,  group.  the  female  In  descent  by  t o each  groups  ny.ie.gg)  groups.  day  segmentary  manner,  the s o c i a l  by  female of  trace  of  the  their  experience  membership  t h e m a x i m a l exogamous l i n e a g e  are  3 5  village  their  the  who  of t h i s founder  present  i s determined  this  founder  of the  life  Project  The  is  are r i v a l  localized  m e n t i o n e d , no  members a r e  Furthermore, the  Health  were i d e n t i f i e d  i s , a s was  patrilineage.  3  descendants  villages  matrilateral  descent  patrilineage. *  and  I n s t e a d , t h e r e a r e groups of  a recognized  eponym o f t h i s of  There  Village  (see 3.3. J) , t h e  were e l e c t e d  after  the  Health  H e a l t h Development  explained earlier (VHCs)  of  Village  more t r a d i t i o n a l  Saradidi Sural  H e a l t h Committees  per  experience  (VHCs) e x p o s e s t h e  of the  (SBHDP).  and  Function of the  or  of  i n the  "clan").  3 6  161 The d h o o t  (or c l a n ) ,  l i n e a g e segment land-holding dhoot) this  u n i t of t h e jweag  a council  affairs  area).  of  lineage elders  all  encompassing  leadership  is  (or v i l l a g e , For  The  Committee  village  t h e SHHDP  Committee i s n o t headman)  other  of  elders  of the V i l l a g e ,  vested  i n these  derived  from  Village  Health  after  is  Unlike the  professional  lineage  elders  generational  is  between t h e that  by men. together  Committee  Committees  this traditional  lineage elders  Village Health  elders  and g e n e a l o g y ,  difference  dominated  representative  the  of the  only  i n t h e more  and  3 8  i s patterned  lineage  of  is  reckoning.  council  council  council  Furthermore,  on s o c i o - e c o n o m i c a n d / o r  level  organization  the dhoot  work  members whose s t a t u s and a u t h o r i t y  the authority  The  on  (EC)  This  subtribe).  this  manages t h e  i t organizes  and d i s p u t e s . .  (Luo f o r  within  structure.  for  manages  as i t i s r e f e r r e d to  example,  on i s s u e s o f s e n i o r i t y  genealogical  in  oganda  by and l a r g e b a s e d  the  and  elders that  (jod.ongo) r e p r e s e n t s  status  considerations, at  corporate  base o f the  which o c c u p i e s  of l i n e a g e  p a r t i e s and r e s o l v e s c o n f l i c t s  Executive  It is a  (the t e r r i t o r i a l  group  o f the dhoot  the P r o j e c t  predicated  the l o c a l i z e d  of land.  There i s  in  r e f e r s to  of a l a r g e r p a t r i l i n e a g e .  or the settlement  3 7  piece  daily  therefore,  the  (VHCs), social  VHC and  Village  the  Health  The  liguru  with  h i s a s s i s t a n t and  are usually  (VHC).  (Kiswahili  represented  On t h e  average*  162 there the  are only  chief's  three  men  on  r e p r e s e n t a t i v e i n the  attend the c h i e f ' s  baraza  administration  policy  in  are  the  wuon d a l a )  village.  villages' male VHC  v i r t u e of On  the  because of  the  of both  in  the area.  of  t h e men  The  income-generating  express  Executive  VHC  to  i n the area The  when  liguru  household heads  (in  in  the  are e l e c t e d to the  Towards H e a l t h a r e on  VHC  become  (VHsTH).  the  As  Committee  by  a month  to  meets o n c e o r t w i c e v i l l a g e and  Project. and  in their  the f e l t  the  and  t h i n k " and  (EC)>.  the to  men  opportunity both  men  plans  is and  people,"  through,  the  to  the needs of the  the  given  wishes  are compelled  Village  is  women  and  Furthermore, s i n c e the the  have  Committee t h a t  effect  response  needs of  a  i s s u e s they  of v i l l a g e d e v e l o p m e n t  village.  "knows h e r  the  drawn i n t o t h e  matters  projects,  Committee  As  women,  women a r e  people  (VHTH)  i s required  h a v e been s e l e c t e d t o  problems that  c h i l d r e n i n the  Health to  men  regarding  how  women who  Helpers  the  work t h r o u g h t h e  "knows  is  duties."  to  and  two  problems i n the  more s u p p o r t i v e  himself  respective families  member i n d i c a t e d , " t h e y  average,  constituted  meeting)  to eighty  women who  Village  their  d i s c u s s the faced  the  liguru  i s s u e s are d i s c u s s e d .  their  or  The  v i l l a g e and  (public  fifty  and  T h o s e one  i n most c a s e s  that one  and  turn represents  Luo,  t h e VHC.  be  women liguru  Helper  Towards  opportunity  i s given  village  community  to  the  163 3.4.2.2 The was  The  R e l a t i o n s h i p t o t h e E x e c u t i v e Committee  raison djetre  for villages  to  disease prevention c o n s t i t u t e the the  in  and  of  their  the  Village  select  village  activities  {VHsTH)  of  volunteers  h e a l t h promotion body  their  to  who  Village  work i n  cases,  should  one  purpose  or  two  (see  development (VHCs)  of the  Helpers  Towards  purveyors  SRHDP  a monthly  reports to progress  the  for financial  care  technigues  turn,  Village the  the  now  knowledge and  Committee  (EC)  of  group  purpose.  In  most  for  this  in  the.  on  Committees  Village  ;  experienced as  well  to as  be of  obligated to  send  indicating  their  activities,  through and  villages.  knowledge.  Executive  Health Committees,  activities  are  own  are  reviews  the  as a  V i l l a g e Health  t h e VHCs  EC  Health  decided  later  basis,  assistance,  to  support  Originally,  was  (VHsTH)  have e a r n e d  and  Towards  presented  only  in  a d d i t i o n a l f u n c t i o n .of i n i t i a t i n g  their representative Village In  and  (VHC).  trained  women were  that  with i n c o m e - g e n e r a t i n g  much t h e y  met  projects i n their  health  income-generating  how  It  Health  of  Helpers  for this  respected  were a s s i g n e d t h e  be  knowledge,  the v i l l a g e .  trained  3.4.3).  income-generating  On  be  to  Committee  t h a t would s u p e r v i s e and  c o u n c i l of e l d e r s i n each v i l l a g e as  Health  {EC)  a statement  these a c t i v i t i e s ,  reguests  a r e p o r t on t h e a c t i v i t i e s  Helpers  Towards H e a l t h  reguests f o r assistance occasionally  income-generating  visits  of  (VHsTH). from  the s i t e  projects  of  in  the of the  164 villages,  and i s c a l l e d  on  to  " l e a d " and  guide  i n the  a f f a i r s of the v i l l a g e . In  Hay o f 1981,  (EC)  t h e S e c r e t a r y o f t h e E x e c u t i v e Committee  was p r e p a r i n g a s c h e d u l e  sites  of  members  village  to the  v i l l a g e s on  income-generating  a rotational village  opportunity  to display  The  basis,  projects  t o the v a r i o u s  projects.  E x e c u t i v e C o m m i t t e e (EC)  support o f  3.4.2.3  of visitations  The e l e c t e d  would  thereby  and g i v i n g  visit  these  indicating  their  the v i l l a g e r s  the  what t h e y had a c c o m p l i s h e d .  The R e l a t i o n s h i p t o t h e V i l l a g e H e l p e r s Towards H e a l t h JVHsTH) men  who s i t on t h e  VHsTH.  The work o f t h o s e  is  much  very  VHCs a r e a l m o s t  e x c l u s i v e l y not  women who a r e t h e v i l l a g e ' s  appreciated,  and  the  VHsTH  women t h e m s e l v e s  are  s p o k e n o f i n t e r m s o f h o n o u r and r e s p e c t : The V i l l a g e p e o p l e ... them.  H e l p e r Towards H e a l t h (VHTH) knows h e r i s n o t h a r s h ... a n d i s a l w a y s w i t h  The VHTH l e a v e s h e r work i n t h e shamba come a n d work a t t h e c l i n i c .  (garden)  to  The VHTH i s a " h e l p e r " who s e r v e s and comes t o t h e rescue of people. Since the  Village  Helpers  Towards H e a l t h  these kinds o f s e r v i c e s i n the v i l l a g e , that to  i t i s the r e s p o n s i b i l i t y  their  of  (VHsTH)  provide  t h e VHC members s a y  the people  t o "give  honor"  VHsTH, a n d t o r e w a r d them i n a p p r o p r i a t e ways.  traditional traditional  Luo s o c i e t y ,  t h e nyamrerua  health, t e c h n i c i a n )  3 9  i s  In  (Luo f o r h e r b a l i s t o r the  herbalist  cum  165 traditional times of After  birth  attendant  i l l n e s s or  she has  (TBA)  when t h e r e  offered  her  who i s c a l l e d  is a  difficult  assistance,  f o r her services  paid  She m i g h t b e g i v e n ,  eggs, soap, a c h i c k e n , the  i n kind  is  rather  than  f o r instance,  some  o r some v e g e t a b l e s f r o m  Problems o f Development: Health Income-Generating P r o j e c t s  t h e shamba o f  C a r e Knowledge o r  H i t h t h e development o f income-generating heels  of  Health  a newly t r a i n e d  (VHsTH), v i l l a g e  VHC  health  nyamrejrua  community  who  should  practitioner  conforms be  whose  members.  perceive  that  clinic.  Host  their  a  work On  to  modes  therefore,  VHTH i s  along  to acquire  image  and  somewhat  of  what  Many  a  health  however,  by they  by  been  the given  and a r a i n c o a t  the r a i n y season;  bicycles.  with a  sustained  "protected"  (flashlights) ,  on  perceptions  oriented  hand,  some o f  villagers  have  w i t h t h e s e new a c c o u t r e m e n t s and  the  opportunity  the  VHTH may a l s o be r e c e i v i n g a s a l a r y  the  Saradidi  clinic.  and  t r a i n e d VHsTH h a v e  torches  been i s s u e d that  their  other  Towards  are confronted  i s integrated the  Helpers  on t h e  representatives  traditionally  work e a s i e r d u r i n g  them have a l s o felt,  —  of t h e newly  gumboots, u m b r e l l a s , make t h e i r  conflicting  On t h e one hand, t h e y  worker  projects  cadre o f V i l l a g e  members a n d t h e i r  are experiencing  of development.  to  pregnancy.  patient.  3.4.2.4  the  during  the nyamrerua  usually reciprocated f o r w i t h money.  on  "modern" h e a l t h . c a r e  knowledge,  (or a l l o w a n c e )  from  166 Currently,  these i s s u e s  formed V i l l a g e H e a l t h are  be t h e i r  selected  VHsTH.  because  (important  Should t h i s they  are  a r e motivated  business  {important  t h e implementation  3.4.3  person, thay  The P r o j e c t  in  3.4.3.1 The doctor  view  o f EC and VHC care  most a b l e  component  interested  activities)?  care.  ( D r . P) was e l e c t e d b e c a u s e he " i s a  person of  of  in  felt-needs  the  health  i n the f i r s t  the area.  credited  with  care."  Saradidi  they f e e l  t h e most a p p r o p r i a t e in  health  I n terms o f  t h e community  "community-based  CBHC might b e  i s  members.  (SRHDP),  was D r . P who m e n t i o n e d  Director  industry,  The F u n c t i o n o f t h e P r o j e c t D i r e c t o r i n t h e 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  Development P r o j e c t  the  small  requirements f o r a person  a n d k n o w l e d g e a b l e i n community  strategy  caring  D i r e c t o r (PD)  Project Director  health  and  nyamrerua), or  the areas of  of income-generating  women who  might a s k , be  compassionate  They do n o t want c o m m u n i t y - b a s e d h e a l t h They want a c l i n i c ! [ P r o j e c t D i r e c t o r , SRHDP)  the  recently  (VHCs i n a r e a s B and C) who  c h a r a c t e r i s t i c s o f the t r a d i t i o n a l  because they  in  Committees  a f f e c t i n g those  i n the process o f s e l e c t i n g f o r t r a i n i n g those  will  and  are  This i s  the c e n t r a l  Sural  that  Dr.  t o advise  P i s the  them i n t h e  care.'! . A f t e r place  that  strategy  Even  a l l ,i t  t h e model o f  f o r addressing  though  introducing  Health  this  the  Project  idea  for  167 development, and  position  Project In will  EC  and  VHC  leaders reiterate  i n t h e community  as  persons  his  own  words,  take time  to  the  into  Project Director  reeducate  i n the r u r a l  socialized  people  a r e making  areas of Luoland,  expecting  the  the  nurses,  and  t h e ambulances  professional health care community  workers.  members t h e r a p e u t i c a l l y  illness  problems.  these practises  While  were n o t  o r g a n i z a t i o n and  was  It  in  the  been  clinical/  want d o c t o r s ,  t o t a k e them  managed  The  have  for They  to  times,  their  the  these  however,  own  c o n t e n t s and  disease  methods o f principle  support i n the h e a l i n g  i s these structures of  re-emerge  says,  always e f f i c a c i o u s ,  o f community sound.  he  In former  the  that " i t  t o CBHC."  need  health care services.  drugs,  feels  back  curative-oriented  must  who  preeminence  work.  peasants  and  their  process  s o c i a l support  accomplishment  of  the  that  Saradidi  Project. Nevertheless, realize compelled community of  that  until  "prevention  t o abide leaders.  t h e community  k o n y i r kende) provides  the  the  by He  people  is  the has  better  wishes  i n constructing  essential  I n any  referral  Saradidi  come  to  he  is  the c o l l e c t i v i t y  of  than  of  supported,  dispensary.  of  cure,"  t h e r e f o r e , the  the  self-help  event, base  extension h e a l t h care workers  [ t h e Community  or  Eventually,  VHsTH)  i n t h e community.  (in  such  for  he  efforts  the Health  a  Luo, clinic  work  of  Workers  i s convinced.  168 the  actual  focus  prevention  and  of  the  health  promotion  p r o v i s i o n of Maternal c h i l d (FP)  Project Director  one  and  rationale position  on  activities  Health  disease  through  (MQH) and F a m i l y  to  says —  himself  and  development point  rather  i s held  in  the  Planning  that  a  The  subservient he t o o wants  personal  and  a p r o f e s s i o n a l and  p a r t i c u l a r stance  That  i s , by  position  accountable to  c o n t r o l over . t h e d e c i s i o n s  merely  this  external  capacity."  a somewhat  From  unusual. ,  the P r o j e c t  with  Project i s that not  o f view,  a link  advisory  venture.  i n an a d m i n i s t r a t i v e  Project  an  of the  a . community  administrative he  in  himself  i n the a f f a i r s be  and f o r m i n g  acting  f o r placing  self-serving  so  be  identifies h i srole i n  of "facilitating  resources,  it  will  coverage.  The as  Project  i s —  not p l a c i n g  where e v e r y o n e i n t h e  him, are  he  has very  made i n  little  the Project.  For  example, w h i l e he h a s been a b l e  t o arrange f o r funds f o r  the  Project  International  Assistance  the Executive  Committee  through Family  Planning  £FIPA),*°  the elected  have been  made r e s p o n s i b l e  these funds. "stranded of  "seed  projects, devices. philosophy  Dr.  leaders  money" f o r  but  the  t h e community constructive  o f CBHC,  f o r the  P i s consulted  or i n t r o u b l e , "  As  on  actual allocations  when t h e  i n the s p e c i f i c  village-based leaders as t h i s  the Project  are  of  EC members a r e disbursements  income-generating left  to  their  sounds i n terms Director  i s still  own  of the held  169 responsible  f o r the deployment  of  funds to e x t e r n a l  funding  agencies.  3.4.3-2 Dr.  The E x p e r i e n c e o f t h e P r o j e c t D i r e c t o r W i t h o u t t h e S a r a d i d i Community P  straddles  leadership  groups i n  background,  in  number o f the  personal  accomplishments. Director  a  Project  t h e S a r a d i d i community. h i s land-holdings  outside  the D i s t r i c t  of  c h i l d r e n are s u c c e s s f u l Nairobi. training the  Dr.  present time  Nairobi.. converse  with  leaders  because  accomplishments church leaders, the  Saradidi  but a l s o  an A m e r i c a n  Lecturer  of  legs,  in  i n the  Saradidi  their  economic  and c h i e f s ) .  community  He  respected  cane  fields  because h i s  with  University  Director  i s able  community  and  graduate  the Department  who  At of of to are  or  professional  teachers,  businessmen,  i s influential  as w e l l b e c a u s e o f  funding  elder  University.  of Medicine,  headmasters,  Project  w o r k i n g i n Kisumu  p o s i t i o n , the P r o j e c t  leaders  l i n k s with e x t e r n a l University.  a  the f a c u l t y  In this  —  a medical doctor  H e a l t h from he i s  Community H e a l t h ,  is  the  i s not o n l y has sugar  professionals  family  lineage  he  of Siaya  P himself  i n Public  —  and  professional  respected  His father  because of  and  his  h i s background,  son o f a h i g h l y  and  religious,  because o f  convictions,  I n terms o f  i s the only  social,  Hithin  organizations  outside  of  his professional and  p e r s o n s a t the  170 Dr.  P also describes  Christian  .  .  organization  himself  actively  at  Saradidi."*  He  1  and  e x p e r i e n c e s of  area,  has  advised  relating  to  (SRHDP).* leaders will do  the He  2  who  does  are  represent  not  their  the  Rural  on  evangelical local  church;  understands  the  "saved" C h r i s t i a n s i n to  be  jealous  Health  u s u r p the  represented  i n the  therefore  them not  Saradidi  a "born-again  involved  perspective and  as  in  matters  Development  Project  authority  the  of  Executive  i n t e r e s t s and  the  those  church  Committee,  concerns i f c a l l e d  but on  to  so. Given t h i s  Director various and  is  religious,  Project. with  Committee  (EC)  i n the  Outside  University  of  provides  donors  and  authority  position  him  him  ranks.  with  the  aligns  Executive sustains  i n the  political,  without  status  widely-dispersed  to and  For the  the  m e d i a t e and  bridge  example,  majority  his  of l e a d e r s  with  funding  village-based  Project, the  his clout  organizations  within  on  the  affinities leadership  position needed  the  professional  while h i s church-related  the  Project  p r o f e s s i o n a l groups  traditional,  him  base,  in  "interested"  at  the  dealing in  the  Project. H h i l e the the  pQSition  V i l l a g e H e l p e r s Towards to  a f f a i r s of the most  visible  r e c o n c i l e these Project,  individual in  t r a d i t i o n a l Luo  the  Health  (VHsTH)  d i f f e r e n c e s i n the  Project  Director  are  everyday  i s often  t h i s s t r a t e g i c maneuvering.  c u l t u r e , there  was  a place  for a  man  in  such  the In as  171 this.  The j a b i l o  functioned  integrated  social  community.  While t h e l i n e a g e  matters  of  localized charisma  political  (the  iabilo)  and  i s known  Saradidi  role  The  sub-locations  (oganda)  community t h a n  power  endowed  (the t r a d i t i o n a l  i s somewhat  analogous  to  Rural  Health  development  of the  income-generating to s t a b i l i z e  projects,  and i n t e g r a t e  the the  with  area  Project  In  was p r o v i d e d  Saradidi  Rural  by the  Health  was a b l e  of t h e i r  affiliations,  the  jabilo current  CBHC  and  functions  i n t e r e s t s o f e v e r y member o f Originally, this  "founding  Development  Chairman" o f  Project  t o persuade people  clan,  iabilo),  the  Director  i n the S a r a d i d i Primary School). who  spiritual,  through  community i n t h e work o f t h e P r o j e c t . ,  function  and h o n o u r e d  the r o l e  of  political  with,  and West  L u o meaning o f  situation  regardless  of  territorial  East  D i r e c t o r i s more r e s p e c t e d  Luo s o c i e t y .  leader  man  segmentary  Saradidi  traditional  of  more  coincides  o f Asembo  in  headmaster  this  3  divided,  fulfilled  the  the  Project.  charistmatic his  in  i n t o the l a r g e r  a s t h e community i n t h e  While the P r o j e c t the  (dhoot),*  or  arbitrated i n  affairs  these  (pjjanda).  two a d m i n i s t r a t i v e  (subtribe)  (iodgngo)  ritual  times of c r i s i s  a r b i t e r i n the  2.St§.nda  elders  brought  the  in  the  communities  of the subtribe  Development  of  and  clan-based  divsions during unit  order  as the s o c i a l  religious,  i n response t o  (Mr.  M,  the a  He was t h e kind, t o work  together  professional, commonly  or  perceived  172 community and  problems  clinical  however, involved  health  the in  In  Saradidi of  process  fiural  leaders  merely  express  the  on  lack  of  Project.  professional  status  businessmen) . the  nyamrerua  The  knowledge they  is  implementing  an  the  Project  the  (teachers,  the  needed  are  Committee  honoured  Project with  community.  the  in  Director external  (EC)  who  have  the  of  Health  achieved  of  agencies,  the  as care  SEHDP.  interchange  donors,  weil as  and  (VHsTH)  health  symbolizes the  worthwhileness of  elders  t o them  the  context  functions as  bring  ministers,  attributed  because  the  lineage  headmasters,  traditionally  have a c q u i r e d  of  leaders  and  example,  V i l l a g e H e l p e r s Towards  government m i n i s t r i e s , and persuades people  of  Many o f  of t r a d i t i o n a l  For  Executive  advice  serve  i n t e r e s t groups.  amalgamation  the  (SEHDP) , d i f f e r e n t  t o make  personal  the  respect  and  lastly,  and  recommendations of t r a d i t i o n a l , w e l l as  command  organizing  structures.  {jodqngo) as  a  i n the  died,  deliberately  i n f o r the  Development P r o j e c t  authority  together  as  suddenly  more  as t o f i l l leadership  unemployment,  When ha  became  h a v e emerged  not  representatives  that  so  of  Health  leaders  modern  And  Director  comprehensive  community and these  Project  services)..  water,  The P o s i t i o n o f L e a d e r s i n t h e D e v e l o p m e n t o f Community-Based H e a l t h C a r e : The S i t u a t i o n o f Saradidi the  types  care  Project  the  s y m b o l i c and  3.4.3.3  [in t h i s instance,  a leader  working  and who  together  173 While t h i s  image o f  participation everyday  in  that  in  For  threaten  SBHDP i s  example,  group.,  instance,  ordered,  the  the P r o j e c t  community  participating for  the  affairs  competitive..  collective,  ideal,  are  decisions  stability  accused  While  Project Director,  i t i s very d i f f i c u l t  since  they a d m i n i s t e r  villages (EC); the  one  EC  there  w h i l e o t h e r s have  and  Some o f t h e s e organizational recommended,  the  election  stand  members  w o u l d be c o m p r i s e d  of n o t  this  basis  of  at  about  Committee  a l l .  (nyiego) ,  on  Then  village  differences  future  through  Project  f o r longer  that  t h a n a two y e a r  he h a s  period t o the  a r t i c u l a t e d i n the on  the p r o f e s s i o n a l  i n d i v i d u a l s as w e l l .  representation,  has  p e r s o n on t h e E x e c u t i v e  representation  only  simple,  Director  additional condition  (which  t  unsalaried  by t h e  representatives  sectarian  t h a t no  With t h i s  SBHDP C o n s t i t u t i o n )  f a r m e r s and  has t h r e e  The  f o r example,  Committee.  funds  work i n t h e P r o j e c t . ,  changes.  o f EC  the Executive  p r o b l e m s c a n be r e c t i f i e d  (EC) c o u l d  Project  Furthermore, c e r t a i n  clan r i v a l r i e s  undermine t h e c o o p e r a t i v e  Committee  on  r e l i g i o u s and  taken  t o do a n y t h i n g  no r e p r e s e n t a t i v e  are the t r a d i t i o n a l  and  (EC) members have*  be r e p r i m a n d e d  the Project.  particular village  guarrels,  on  might  are over-represented  tense  sometimes  spending  inappropriately.  it  are  actual,  and t h e i n t e r e s t s o f e v e r y  of  they  the  oftiaes  E x e c u t i v e Committee  been  and u n i f i e d  i t would b e  the Project elite,  but  O p e r a t i n g on possible  to.  174 prevent  the  potentially  formation  utilize  of  the  power  Projects  blocks  which  resources  could  to t h e i r  own  so e a s i l y .  It  advantage. Certain requires  issues,  the steady,  community  leaders  structures  of  deliberate,  and c o n s c i o u s attempt o f  t o work t h r o u g h  epistemologies,  for  however, a r e n o t r e s o l v e d  so a s thinking  the d i a l e c t i c  to create  innovative  and a c t i n g .  The  example, h a s c a l l e d f o r a r e s p o n s e individual interests must give i n t e r e s t s o f t h e community . . . .  o f competing and  relevant  Project  Director,.  to these p r i n c i p l e s : way  to  the  and, people must l e a r n . t o s e r v e t h e i r community rather than suck from i t what they can g e t f o r themselves . . . These statements morally  express  required  what  most  of the leaders  to accomplish the  feel i s  hoped f o r r e s u l t s i n t h e  Project. The p e a s a n t s o f leaders. that  they  Saradidi  Whether i a b i l o , must  "trustworthy."  have  poverty,  community, members —  "vision,"  and  suggest  social  f o r the amelioration  community.  L a s t l y , they  of  their  they and  feel be  to a r t i c u l a t e future  members - - e g s . , f o r t h e youth  well-being  v i a b l e and a t t a i n a b l e  involvement  being trustworthy,  able  opportunities  and p h y s i c a l a n d  from  "imagination,"  f o r community  employment  deal  jodongo, or nyamrgrua,  They must a l s o be  states of well-being of  expect a great  a lack i n the  o f community s t r u c t u r e s of  these f e l t  needs i n t h e  must be i n d i v i d u a l s w i t h i n t e g r i t y ;  reliable,  and r e s p o n s i b l e  persons i n the  175 life  of  the  community.  epistemological naymrgrija  discrepancies  (VHsTH)  dilemmas  in  In  life  face  i n the  struggle  their  the  and  and  Project  seek  work  of  to  i n  moral  and  area,  the  resolve  their  these  respective  villages.  3.4.4  The V i l l a g e Prevention  3.4.4.1 The agreed  Helpers  Towards H e a l t h  i s b e t t e r than c u r e . ( s l o g a n o f t h e VHTH, SRHDP)  Naming t h e Community H e a l t h name V i l l a g e  Helper  (CHWs)  Project  (SRHDP).  Towards H e a l t h  i n the  44  Saradidi Rural  T h i s was d e c i d e d  a s e m i n a r g i v e n f o r community the  Project.  Director and  worker (VHTH) was  ( D r . P)  Research  After  4 5  discussions  Neighbors,  the gala  moro  Development  participating the  Project  from t h e A f r i c a n  Medical  (AMREF) ,  with  the  United  (UNICEF),  ( g e n e r a l meeting)  decided  name b e s t e x e m p l i f i e d t h e f u n c t i o n t h i s p e r s o n  Nations and World that  would  this  fulfill  h e r work i n t h e v i l l a g e . Originally,  identified. describing the  Health  o f 1980 d u r i n g  l e a d e r s who were  and c o n s u l t a n t s  Foundation  Health  i n August  I n t e r n a t i o n a l C h i l d r e n ' s Emergency Fund  in  finally  upon a s t h e a p p r o p r i a t e name f o r t h e Community  Workers  in  (VHsTH)  the  name  jakony  [Luo  for  helper)  was  T h i s word, however, was n o t s p e c i f i c e n o u g h i n the role  village.  o f t h e Community  Health  The l e a d e r s s o o n r e a l i z e d  Worker  that t h i s  (CHW)  in  person  was  176; similar only  i n characteristics  in  different  this  instance,  armamentarium  traditional  parlance,  in  trouble."  She m i g h t  worker  f o r the  displayed  proposed Worker  be a  the  of V i l l a g e  that  required Worker  selection  we