Participatory problem solving approaches in rural health development

This thesis portfolio deals with the concept of participation in health development in relation to the problems faced by an ethnic minority, the Garo people, in Bangladesh. The thesis portfolio consist out of: an essay on the concept of participation, a proposal for a participatory action research, a report on the exploratory inquiry of the area under study, a presentation outline on participatory evaluations, a reflection on the philosophy of participation and the reality of the social context, and a bibliography on the concept of participation. There is no single interpretation of the concept that has been universally accepted. The literature on community participation can be classified in two main schools of thought: First those who see participation as a means to improve the effectiveness, cost reduction, and efficiency of pre-planned programs and projects. Second, those who see community participation as an end. The ultimate goal, to ensure that people have a voice in decisions affecting their health. This study adopted the second interpretation of the concept of participation. Community participation could offer an answer to the problems encountered in implementing primary health care. The Garo people in Bangladesh face a triple discrimination, affecting the quality of the lives, based on ethnic, cultural and religious difference with their social environment. It is assumed that a participatory approach through self managed health programs could improve the overall quality of life for them. Participation is a controversial concept and its implementation calls for critical changes. First, there is the need for political commitment. Second, the bureaucracy need to re-orient itself. Third, a minimum basic health care infrastructure coverage is a pre-condition as well. Finally, participation calls for capacity building of people. With respect for the critical these changes, and the limitations inherent to the social context in Bangladesh, this study is focusing on participatory approaches in problem solving in health among Garo people. The study is proposing a participatory action research (PAR), using the soft system inquiry approach, aiming at sustainable self managed problem solving programs in health development. In preparation of the PAR a rapid rural appraisal (RRA) was done as a preliminary exploratory inquiry The RRA was designed to answer questions on the viewpoint of local people on the basic minimum needs and the relative degree of readiness of the community for participatory approaches. The findings of the RRA indicate that the entry point for PAR should be the Garo community. Further the findings indicate that the profile of the Garo community is matching with community criteria for participatory approaches. The villagers of the study area, emphasized the need for health promotion, prevention and care activities. Among the pre-defined ten basic minimum needs Garo and Bengali respondents graded access to health care (84%), sufficient food (83%), education (60%), income (57%) and community self-care (46%) as their most important concerns. The PAR will be initiated and facilitated by one evaluator for a period of 12 months. The aim is to stimulate community initiatives to improve the health status of the Garo community in a Garo settlement. The general objectives are: (1) to initiate community based participatory problem solving in health for this Garo settlement, (2) undertake. Implement, and evaluate planned actions for improvement of the quality of life, (3) formulate recommendations related to participatory problem solving, based on the outcome of the research, to the various stakeholders. There are strong indications that the proposed actions are sustainable. The RRA does indicate that participatory approaches are viable within the Garo community in Bangladesh. Working with the Garo people could be an entry point in aiming at improvement of the health systems development by linking peoples’ actions to governmental plans and the local public service infrastrucrture.