1. Presented by:
Narendra Singh
PG JR 1
Department of Community Medicine

2. What is a Community ?????
“A Community is a set of people living
in a particular space or region and
usually linked by common interest”
We all live in a community.

3. WHAT IS PARTICIPATION??????
A/C to Oxford dictionary Participation means
“to have a share in ”
or “ to take part in”.

4. WHY
COMMUNITY
PARTICIPATION
IS IMPORTANT??

5. Participatory development and
participation in development
Participatory development Participation in development
A top down participation in the
sense that the management of
the project defines where,
when and how much the
people can participate.
Bottom up participation in the
sense that the local people have
full control over the processes
and the project provides for
necessary flexibility.
It is introduced within the
predetermined project
framework.
Entails genuine efforts to engage
in practices which openly and
radically encourage people’s
participation.

6. “As an individual I could do
nothing. As a group we could
find a way to solve each
other’s problems”

7. • Success of any intervention in development and
work depends on the confidence built and the
power given to people to decide and take
community initiatives.
CONSENSUS IS ITS KEY
• The primary factor for promoting consensus and
instilling confidence is PARTICIPATION.

8. INTRODUCTION
• Development intervention approaches in INDIA
over the past 60 years have been very much a
‘supply oriented one way traffic’.

9. LIMITATIONS OF THE APPROACHES
A top down approach
Target oriented
Non involvement of the people
Vertically controlled sectoral approach without any horizontal
coordination
The dominant development thinking oriented towards greater
inputs (supply) than what people demanded
Near total absence of self confidence and even self respect
Lack of appreciation and promotion of indigenous technical
knowledge and resources.
The ever growing recipient attitude.

10. COMMUNITY
PARTICIPATION
• a process by which people are enabled to
become actively and genuinely involved in
defining the issues of concern to them, in
making decisions about factors that affect
their lives, in formulating and
implementing policies, in planning,
developing and delivering services and in
taking action to achieve change’

11. WHO SAYS
Community participation is a process
by which individuals and families
assume responsibility for their own
health and welfare and for those of
community and develop capacity to
contribute to their and the community
development.

12. HISTORICAL BACKGROUND
• Establishment of primary health units at the
village level to bring the service as close to the
people as possible, cooperation of the people in
the health programme, and adequate medical care
for all individuals, irrespective of their ability to
pay for it, were included in BHORE REPORT.
• COMMUNITY DEVELOPMENT PROGRAMME
LAUNCHED IN 1952, the setting up of one Primary
Health Centre (PHC) per Block was accepted by the
Central Council of Health in 1953 .

13. Contd…
THE SHRIVASTAVA COMMITTEE: Employment of
paraprofessional or semi-professional workers
from the community itself as a link between the
Sub-Centers and the community to provide
simple services was one proposal.
They opted for the Community Health Worker
scheme to meet the insufficiency of doctors.

14. The Primary Health Care Movement
towards Health for All by 2000AD
Alma Ata, 1977
• Emphasis from
“Health care for the
people”
“Health care by the people”
concept of primary health care
Democratization of the health services

15. The International Conference on Primary Health Care calls for urgent
action by all governments, all health and development workers, and
the world community to protect and promote the health of all the
people of the world by the year 2000.

16. Alma Ata declaration
DEFINED PRIMARY HEALTH CARE:
“essential health care based on practical,
scientifically sound, and socially acceptable
methods and technology made universally
accessible to individuals and families in the
community through their full participation and
at a cost that the community and country can
afford to maintain at every stage of their
development in the spirit of self-reliance and
self-determination” (WHO, Alma Ata Declaration VI, 1978, p.1).

17. STAGES OF PARTICIAPTION
Level I.
• Community receives benefits from the service but
contributes nothing
Level II
• Some personnel, financial or material contribution from
the community ,but not involved in decision making.
Level III
• Community participates in lower level decision making
Level IV
• Participation goes beyond lower level decision making to
monitoring and policy making
Level V
• program is entirely run by the community ,except for some
external financial and technical assistance.

18. DEGREES OF COMMUNITY PARTICIPATION
Collective action
Co-learning
Cooperation
Consultation
Compliance
Co-option

19. • Co-option
• Token involvement of local people
• Representatives are chosen, but have no real input or power
• Compliance
• Tasks are assigned, with INCENTIVES
• Outsiders decide agenda and direct the process
• Consultation
• Local opinions are asked
• Outsiders analyze and decide on a course of action.
• Cooperation
• Local people work together with outsiders to determine priorities
• Responsibility remains with outsiders for directing the process
• Co-learning
• Local people and outsiders share their knowledge to create new
understanding
• Local people and outsiders work together to form action plans with
outsiders facilitation

20. Community Action Cycle
Prepare to mobilize
Prepare to scale up
Explore the common issue
& Set priorities
Organize the community
For action
Evaluate together
Plan together
Act together

21. Citizen control
Delegated power
Partnership
Placation
Consultation
Informing
Therapy
Manipulation
Original Arnstein's
ladder of participation
Degree of
citizen power
Degree of
tokenism
Non
participation

22. 1.Manipulation and 2.Therapy
1. Both are non participative.
2. Aim is to cure or educate the patients.
3. The proposed plan is best and the role of
participation is to achieve public support by public
relations.
3. Informing
1. A most important first step to legitimate
participation.
2. Too frequently the emphasis is on one way
information. There is no feedback.

23. 4.Consultation
Attitude surveys ,neighborhood meetings and
public surveys.
Arnstein feels still this as a window dressing trial.
5.Placation
Allows the citizens to advise plan but retains the
power holders the right to judge the legitimacy or
feasibility of the advice.
6.Partnership
Power is in fact redistributed between the citizens
and the power holders. planning and decision
making responsibilities are shared.

24. 7. Delegated power
1. Citizens holding a clear majority of posts in
committees with delegated power to make
decisions.
2. Public now has the power to assure
accountability of the programmed to them.
8. Citizen control
Handles the entire job of planning, policy making
and managing the programmed.

25. How can you build community
participation “community
mobilization”
A process whereby a group of people
become aware of a shared concern or
common need and decide to take action
in order to create shared benefits.

26. ACTION PLAN
• Steps taken to meet the health
needs of the community based on
the resources available and the
wishes of the people (felt need).

27. PARTICIPATORY RURAL APPRAISAL
PRA is “a family of approaches and
methods to enable local (rural or urban)
people to express, share, enhance, and
analyze their knowledge of life and
conditions, to plan and to act.”

28. PRA
• Participatory Rural Appraisal is a methodology
for interacting with villagers/community,
understanding them and learning from them.
• It shifts the initiative from outsider to villager.
• PRA seeks to empower. It empowers the weak,
the powerless and the marginalized, by enabling
them to analyze, discuss and deliberate on their
condition.
• Believes in flexibility in choosing methods.
• Reversal of learning.

29. PRA Techniques / Tools
1. Village mapping
2. Transect walks
3. Mobility mapping
4. Seasonal Diagram
5. Matrix scoring and ranking
6. Trend analysis
7. Venn Diagram
8. Daily activity Chart
9. Force Field Analysis
10.Causal Impact Diagram
11.All undertaken by local people.

30. PARTICIPATORY LEARNING AND ACTION
(PLA)
1. Approach for learning about and engaging with
communities.
2. Combines an ever-growing toolkit of participatory
and visual methods with natural interviewing
techniques.
3. Intended to facilitate a process of collective analysis
and learning.
4. The approach can be used in identifying needs,
planning, monitoring or evaluating projects and
programmes.
PROBLEM TREE

31. PRA Techniques / Tools
1. Participatory mapping or modeling

32. 2. Transect Walks/Group Walk
To observe, to listen, to identify different zones
or conditions, ask relevant questions to identify
solutions

33. MOBILITY MAPPING
Explore the movement pattern of an individual, a
group or a community.

34. Seasonal calendar
1) drawn by villagers with
locally available materials
2) Depicting Local language
months, seasons
3) Festivals/ social events,
crops grown
4) Occupation / income
generation
5) Periods of plenty/ scarcity
6) Common diseases

35. Daily Activity chart
1. illustrates the different kinds of activities carried out
in one day.
2. Time management - Effective utilization of time
3. To look at relative work-loads in different groups.
4. How is his or her time spent?
5. Period of relaxation, recreation, physical activity,
Personal care, rest.
6. Income generation, productive work, community
work
7. Whether women spend more time in collecting
water and firewood?

36. Daily Activity chart

37. VENN DIAGRAM
1. To know the individual and institutional linkages
and relationships with the community.
2. Visual depiction of key institutions, organisations
and individuals active in the community,
responsible for taking decisions.
3. Degree of contact between them in decision-making
4. Size of circle – importance
5. Degree of overlap – Degree of contact

39. FLOW DIAGRAMS
CAUSAL AND IMPACT DIAGRAMS
1. To identify the causal factors of health problems
2. The various impacts of diseases, as perceived by the
villagers.
3. Planning and evaluation tool.

40. Trend analysis
• Attempts to study people’s account of the past of
how things that were closer to them have changed
at different points of time.
• A useful tool for monitoring and evaluating a
project.

41. PAIR WISE RANKING
• Compares pairs of elements, such as the
preference for needs, problems, etc.
• Leads to analysis of the decision making rationale.
IMPACT / MATRIX RANKING AND SCORING
• To rank the problems in the community based on
the intensity, the need for immediate or late
action.
• Helps to prioritise the problems and needs.

42. Force field analysis
• Developed by Kurt Lewin
• Technique to visually identify and analyze forces
affecting a problem situation so as to plan a
positive change.

43. PROCESS OF COMMUNITY PARTICIPATION IN
HEALTH PROGRAMMES
Analysis of the needs and requirements of the people
in the community
Designing the primary health program to meet the
needs of the people with the involvement of the
people.
Educating the people through formal and informal
channels to make them aware of the program and
utilizing the resources available with them
Kindling and generating interest among people to
keep up the momentum through the provision of
resources not available locally.
Leaving the program to the care of the people with
aided guidance

44. Contd..
Providing aided guidance to handover
the programme to the people
Occasional follow up to sort out any
problem
Birth of a permanent community
managed PHC
Birth of a healthy society

46. RECOGNISING THE CRISIS IN INDIA
Accessibility ?
Affordability?

47. PANCHAYATI RAJ
1. Balwant Rai Mehta committee (1957)
2. Started in 1959:by 1964 in whole India
3. “An interconnected system of democratic
institutions at the village, block, and district
level”.
4. 73rd and 74th constitutional amendment act 1992
made health and family welfare and education
responsibility of village Panchayats.

48. THE COMMUNITY HEALTH VOLUNTEER
SCHEME
THE NATIONAL PLANNING COMMITTEE 1946: Planned to
train young men from the villages for 9 month in simple
curative care and hygiene for PHS at village level.
Program was withdrawn in 1951 .
Voluntary agencies picked idea in 1960 and 1970, and used
auxiliary personnel for the delivery of primary health care.
Successes of it received international recognition and
together with the China example of “barefoot” doctors
served as role models for the Indian government

49. Contd…
In 1977, govt. again adopted the approach but &
one doctor/PHC for training purposes(BJP GOVT).
New govt. renamed the programme in Community
Health Volunteers .(INC)

50. THE INTEGRATED CHILD
DEVELOPMENT SERVICE SCHEME,1975
1. Community-based.
2. Local woman is selected and trained for three month
to become the Anganwadi worker.
3. Covers a population of 1000.
4. Anganwadi center she prepares and distributes food,
maintains growth charts, weighs children and gives
non-formal education to the beneficiaries.
5. Also cooperates with the Primary Health Centre staff
for health check up, immunization and referral.

51. COMMUNITY PARTICIPATION IN NATIONAL
FAMILY WELFARE PROGRAM- MAHILA
SWASTHYA SANGHS
• Constituted in 1990-1991
• Consists of 15 women , 10 representing the varied social
segments in the community.
• Total no of MSS: 79512, Budget allocation: 1200/year
• Five functionaries involved in women's welfare activities at
village level:
1. Adult Education Instructor
2. Anganwadi Worker
3. Primary School Teacher
4. Mahila Mukhya Sevika
5. Auxiliary Nurse Midwife(ANM)

52. VILLAGE HEALTH AND SANITATION
COMMITTEE (VHSC)
Formed at the level of the revenue village (more than one such
villages may come under a single Gram Panchayat).
Consist of:
Gram Panchayat members
ASHA, Anganwadi worker , ANM
Village representative of any Community based
organization
• CHAIRPERSON : Panchayat member (preferably woman or SC
or ST candidate)
• CONVENOR ASHA if anganwadi worker not there

53. PHC Monitoring and Planning
Committee
Committee monitors the functioning of Sub-centers
operating under jurisdiction of the PHC and develops PHC
health plan after consolidating the village health plans.
Block monitoring and planning committee
Committee monitors the progress made at the PHC level
health facilities in the block, including CHC and develops
annual action plan for the Block after consolidating PHS
level health plans.

54. ROGI KALYAN SAMITI (RKS) /PATIENT WELFARE
COMMITTEE/HOSPITAL MANAGEMENT
COMMITTEE (HMC) .
Bring in the community ownership in running of rural hospitals
and health centers, which will in turn make them
accountable and responsible.
RKS would be a registered society.
• It may consists of:
• Group of users: people from community Panchayati Raj
representative
• NGOs
• Health professionals
• A/C IPHS, it is mandatory for every CHC to have “Rogi
Kalyan Samiti” to ensure accountability.

55. COMMUNITY PARTICIPATION IN
NRHM
10/14/2014 community participation 55

56. INDIA’S COMMUNITY PARTICIPATION LAW:
THE MODEL NAGARA RAJ BILL, 2008
1. India’s first community participation legislation and
creates a new tier of decision making in each
municipality called the Area Sabha.
2. Mandatory reform under the Jawaharlal Nehru National
Urban Renewal Mission (JNNURM), which means that
the various states in India must enact a community
participation law to be eligible for funds under the
JNNURM program.
3. Crucial because the Bill has the potential to empower
people by ensuring regular citizen participation in
decision-making that affects the conditions of their lives.

57. Swachh Bharat Mission (SBM)
1. Started as Central Rural Sanitation Programme
(CRSP) in 1986.
2. With objective of improving the quality of life of
the rural people and also to provide privacy and
dignity to women.
3. With broader concept of sanitation, CRSP
adopted a “demand driven” approach with the
name “Total Sanitation Campaign” (TSC) with
effect from 1999.

59. 1. Implemented with focus on community-led and
people cantered initiatives.
2. Encouraged by the success of “Nirmal Gram
Purashkar” (NGP), the TSC is being renamed as
“Nirmal Bharat Abhiyan” (NBA).
3. Swachh Bharat Mission (SBM) 2014: covers the
entire community for saturated outcomes with a
view to create Nirmal Gram Panchayats with:
Individual Household Latrine (IHHL) of both Below
Poverty Line (BPL) and Identified Above Poverty Line
(APL) households within a Gram Panchayat (GP).

60. SUCCESSFUL INDIAN EXPERIENCES
1. Vadu Rural Health Project (Maharashtra)
2. Comprehensive Rural Health Project, Jamkhed
(Maharashtra)
3. Holistic Modality of Participatory Interface Mechanism
for Integrated Health Care in Rural West Bengal,
Institute of Child Health, Calcutta
4. The Tilonia Model as a New Approach for Cooperative
Development, Tilonia, Rajasthan
5. Sewa rural (Gujarat)
6. Participatory health communication and action
(Madhya Pradesh)

61. QUALITATIVE ANALYSIS OF
COMMUNITY PARTICIPATION
How much does the community know about the
programme?
How much do they know about the organization carrying
out the programme?
How often do they come face to face with the
programme Personnel ?
What responsibilities do they carry out on behalf of the
programme?
What kinds of difficulties do they find in undertaking
these responsibilities?

62. Contd..
 How satisfied are they with the involvement in
the programme and why?
Do they have any suggestions to improve their
participation in the programme?
 Are all sections of the community equally
involved in the programme?
If there is a differential advantage to some group,
why does it happen and who gets the preferential
advantage?

63. OBSTACLES TO COMMUNITY
PARTICIPATION
Absence of confidence and ability of people in the
machinery of health administration.
Unequal domination of power relations in favour of rich
and to the disadvantage of the poorer sections of the
society.
Inaccessible services in right quantity and quality
Rigid bureaucratic set up impeding the people to
participate.
Legal hurdles

64. OBSTACLES TO COMMUNITY
PARTICIPATION
Participation does not occur automatically. It is a process. It
involves time. Hence it may lead to delayed start of a
project.
1. Diverse interests and priorities due to social
stratification
2. Resistance to decentralization and distribution of
benefits
3. Failure to reorient entire health services to primary
health care approach
4. Difficulty in mobilizing uninvolved populations
5. Problems of maintaining sustained efforts

65. PRINCIPLES TO RESOLVE THE
OBSTACLES
• Channelizing the NGO’s to promote health plans
• Effective training of Health personnel in Appropriate
technology
• Responsive administration
• Openness in the sense of having wide contact with the people
• A sense of justice, fair play and impartiality in dealing with men
and matters.
• Sensitivity and responsiveness to the urges, feeling and aspirations
of the common man.
• Securing the honor and dignity of the human being ,however
humble s/he might be.
• Easy accessibility.
• Honesty and integrity in thought and action.

66. Contd…
Inadequate understanding of local talent, abilities and
resources.
Absence of identity with the community among people.
People’s dependence on GOVERNMENT and not on their
self
Heterogeneity of interests
Resistance to empower people
Resistance on the part of certain segment of population
to participate
Sustained efforts missing

67. Contd..
• Effective public relations
• Spread of awareness about the health
activities of the government with the
expectations and aspirations of the people.
• Speedy redressal of public grievances through
a systematic and well thought out
mechanism.
• Sound health system
• Empowerment of the poor
• Developing social networks

68. DISADVANTAGES OF COMMUNITY
PARTICIPATION
1. Participation does not occur automatically. It is a process. It involves
time. Hence it may lead to delayed start of a project.
2. In a bottom-up participation process, we have to move along the
path decided by the local people. This entails an increased
requirement of material as well as human resources.
3. Participation leads to decentralization of power. People at the top
should be ready and willing to share power with the people.
4. Participation sometimes develop dependency syndrome.
5. Participation can result in shifting of the burden into the poor.