Tropical Health Matters

The history of community intervention in Burkina Faso dates back to immediately after the declaration of Alma Ata in 1978. The first community health experiments were carried out in 1979 with the support various development partners with an aim of reducing maternal and infant morbidity and mortality difficult to access health districts where village birth attendants where been trained, equipped and supervised. Today as a matter of policy, Burkina Faso aims at improving the quality of health services and increasing access to health services through community-based health workers (CBOs), civil society organizations (CSOs), non-governmental organizations (NGOs) and associations implements community intervention strategies. with the full participation of communities.[1]

Burkina Faso’s draft strategic plan for community health states that, “Community Health is a multi-sectoral and multi-disciplinary collaborative enterprise that uses public health science and some social science approaches to engage and work with communities. Its purpose is to optimize the health and quality of life of all people who live, work in a given community. It is based on community needs, understanding and community priorities for health.”¹ Community participation is seen as central to achieving universal health care.

The Ministry of Health¹ notes that there has been community participation as part of cost recovery (Bamako Initiative). Communities are part of the management committees set up at the level of the first-level health facilities so that the populations thus participate in the management of health facilities, through these committees. “In recent years, there has been renewed interest in community health with a strong mobilization of civil society through NGOs and associations. Community components are integrated into many health programs. This new dynamic has led to significant progress and positive results in the areas of the fight against HIV, tuberculosis, reproductive health (family planning, health of young people and adolescents), malaria, malnutrition, vaccination, etc.”

The Ministry reports that, “Indeed, the community actors have contributed to the achievement of the results obtained through the implementation of community-based health services, which however remain to be rethought not only in its vision but also to be in phase with that of the universal health coverage. For a better involvement of these actors in the achievement of the health objectives, the main challenges remain their motivation, the reinforcement of their capacities and the collaboration with the agents of health.”¹ Systematic evaluation of such results remains to be done.

While there have not been systematic assessments of these participatory processes in community health, researchers did take a close look at the levels and types of community participation attained in water and sanitation projects in Burkina Faso. The following lessons have implications for involving Burkina Faso communities on PHC:[2]

• Users and Neighborhood groups have a lower level of participation than city and government stakeholders
• It is possible that the social structures and traditions in Burkina Faso do not encourage a more participative approach
• Further study of power structures in Burkina Faso may determine why participation is lower than expected
• There is a significant decrease in participation levels during the design and selection steps of planning as opposed to the earlier stages of problem identification and definiing objectives, and the later stages of option selection and action planning – a question of planning styles dominated by experts

These issues raise questions about the social and cultural aspects of the planning process and about leadership and governance. It would seem that ‘experts’ also need education about how to work with communities.  There are also concerns about the level of community education employed to help community members and CBOs make informed choices. The authors raise another important question concerning expectations that communities will take ownership in the running of projects when in fact these Users have only been asked about their problems and then been informed about a solution.

In another sector the World Food Program developed a diagnostic and planning approach based using community participation and conducted training and practical exercises on “Community-Based Participatory Planning.” The exercise brought many community actors together to identify food security issues such as land degradation, lack of economic activities for residents in the non-agricultural season and floods that block access to health and other services. participators discussions identified community resources to address these issues and demonstrate resilience.[3]

A recent Global Fund grant to Burkina Faso was entitled, “Strengthening health systems and scaling-up of integrated community case management interventions.”[4] Community-based organizations (CBOs) involved in control of the three diseases commonly addressed through integrated Community Case Management (iCCM) – malaria, diarrhea and pneumonia. The program was also expected to strengthen the community workforce be ensuring adequate numbers of functional CHWs. The project received a high level of regular reporting by CBOs (100%), but less than ideal from individual CHWs (83%). This was in spite of the fact that they achieved recruitment targets for ‘functional’ CHWs. Interestingly the biggest problem for the CHWs was the extremely low availability of essential supplies with which they could work (13%). The grant demonstrated the challenges of involving CHWs in more focused activities as opposed to a broader community agenda. Reorganization of the CHW program in the last few years has created a standardized curriculum so that there are two CHWs per village who respond to a variety of community needs ranging from reproductive health to disease control. The problem of adequate supplies and materials to do their work continues, though.

While Burkina Faso has established the basic participatory structures in the form of committees and community agents, the Ministry of Health is concerned that Community participation is low.¹ Lessons from other sectors show possible reasons and solutions and inter-sectoral collaboration, one of the hallmarks of PHC should be used to address the challenges. the MOH of course has its own ideas (listed below) about the root causes of this problem and having identified the following, it should be encouraged to continue efforts to strengthen the roll of the community in PHC:

• lack of social capital (capacities of communities to work together effectively, to identify problems, to prioritize and take charge of them)

• weak involvement of communities in the whole process of implementation.

• greater focus on community diagnosis of needs, assets, and priorities, to develop appropriate intervention strategies, planning, implementation, evaluation

• lack of capacity (skills, human resources, material and time) of community implementation actors,

• lack of accountability of the stakeholders responsible for the implementation of community-based initiatives (CBIs)

• lack of a multi-sectoral approach in the resolution of health problems

Insufficient strategies to combat social exclusion and to take into account specific groups also constitute a barrier to community participation

Partners worry that there is difficulty sustaining CBIs and demotivation of actors (CHWs, facilitators), which can allow morbidity and mortality to remain high in the community. Clearly, investment in strengthening community participation will go a long way in saving lives and promoting health.

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[1] Ministere De La Sante. Draft Strategie Nationale De Sante Communautaire Au Burkina Faso 2019-2023. September 2018

[2] McConville J, Kain J, Kvarnstrom E, et al. (2014) “Participation in sanitation planning in Burkina Faso: theory and practice”. Journal of Water Sanitation and Hygiene for Development, vol. 4(2), pp. 304-312. http://dx.doi.org/10.2166/washdev.2014.125

[3] Ouedraogo, Celestine (2016). Promoting Community-Led Resilience and Development Solutions in Burkina Faso. World Food Program. https://www.wfp.org/stories/promoting-community-led-resilience-and-development-solutions-in-burkina-faso

[4] Global Fund (2017). Burkina Faso BFA-S-PADS Grand Performance Report. https://www.theglobalfund.org/en/portfolio/country/grant/?k=d8f34742-0d57-410c-b5ba-39615edc5785&grant=BFA-S-PADS

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