Development Sustainability Through Community Participation: Mixed Results from the Philippine Health Sector [1° ed.] 1138616524, 9781138616523

Table of contents :
Cover
Half Title
Title Page
Copyright Page
Contents
Figures and Tables
Acknowledgements
Introduction
1 Operationalizing Community Participation and Project Sustainability
2 Does Community Participation Really Matter to Development Sustainability?: Competing Views and Evidences
3 Community Participation, Development Sustainability, and the Decentralization of Health Care Delivery in the Philippines
4 The Cases of Four Philippine Health Care Projects
Conclusions
Bibliography
Appendix 1
Appendix 2
Appendix 3
Index

Citation preview

DEVELOPM ENT SUSTAINABILITY THROUGH COM M UNITY PARTICIPATION

Development Sustainability Through Community Participation Mixed Results from the Philippine Health Sector

JO A Q U IN L. G ONZALEZ HI, Ph.D. Lecturer, Public Policy and Administration Department o f Political Science National University o f Singapore

Published in conjunction with the CEN TRE FOR ADVANCED STUDIES Faculty of Arts and Social Sciences National U niversity of Singapore

First published 1998 by Ashgate Publishing Reissued 2018 by Routledge 2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN 711 Third Avenue, New York, NYI 0017, USA

Routledge is an imprint of the Taylor & Francis Group, an informa business Copyright © Joaquin L. Gonzalez III 1998 All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Publisher's Note The publisher has gone to great lengths to ensure the quality of this reprint but points out that some imperfections in the original copies may be apparent. Disclaimer The publisher has made every effort to trace copyright holders and welcomes correspondence from those they have been unable to contact. A Library of Congress record exists under LC control number: 97077887 ISBN 13: 978-1-138-61652-3 (hbk) ISBN 13: 978-1-138-61654-7 (pbk) ISBN 13: 978-0-429-46193-4 (ebk)

Contents Figures and Tables Acknowledgements

vi vii

Introduction 1

2

3

4

1

Operationalizing Community Participation and Project Sustainability

9

Does Community Participation Really Matter to Development Sustainability?: Competing Views and Evidences

36

Community Participation, Development Sustainability, and the Decentralization of Health Care Delivery in the Philippines

61

The Cases of Four Philippine Health Care Projects

95

Conclusions

131

Bibliography Appendix l Appendix 2 Appendix 2 Index

142 168 172 181 186

v

Figures and Tables Figure 1: Community participation and project sustainability, 1981-90 Figure 2: Community participation and project sustainability: Affirmative view Table 1: Internal and external determinants of project sustainability Table 2: Pessimists and theirdeterminants

vi

4 37 43 48

Acknowledgements Numerous individuals and groups made the researching and writing for this book, which started as my doctoral dissertation, possible. Sincere gratitude goes to my guru, Dr. James B. Mayfield, who gave his unending support and encouragement, from the start, the completion and revisions of this project. I would also like to thank my other mentors at the University of Utah who showered me with constructive ideas and thoughts: Drs. Daniel McCool, Howard Lehman, Yangi Tong and Stephen Reynolds. After graduate school, valuable intellectual guidance and stimuli were provided by Ed Campos, Manny Jimenez, John Page, Lyn Squire, Bhuvan Bhatnagar, Aubrey Williams, Julie Viloria, David Steedman and David Williams during my twoyear stint at the World Bank in Washington, DC. My sincere appreciation to many friends and colleagues at the National University of Singapore, Centre for Advanced Studies, Institute of Southeast Asian Studies, Philippine Embassies in Singapore and the United States of America, the University of the Philippines, De La Salle University and the Philippine Department of Health. Special mention goes to Assoc. Profs. Jon and Stella Quah, Assoc. Prof. Leo Suryadinata, Assoc. Prof. Lee Boon Hiok, Dr. Ho Khai Leong, Dr. Shamsul Haque, Dr. Gambhir Bhatta, Dr. Peggy Teo, Mr. Ronald Holmes, Mr. Rizal Buendia, Mr. Benito Bengzon, Dr. Trinidad Osteria, Dr. Exaltación Lamberte, Dr. Ledivina Carino, Dr. Amelia Varela and Dr. Victoria Bautista. This study would not have taken off the ground without the generous financial and technical support of FHP Health Care (Utah) and the Policy Research and Operations Policy Departments of the World Bank. Moreover, I am indebted to two anonymous referees who gave helpful comments and excellent suggestions. Thanks to Edith Gonzalez and Susan Lopez-Nemey for providing editorial assistance. Acknowledgements also go to the Gonzalez and Borbon families for being there during the emotional “ups” and “downs” inherent to long-term endeavors such as this book. Above all, I am grateful to my wife Edith Borbon Gonzalez and my daughter Elise Borbon Gonzalez for their patience, understanding and inspiration. Joaquin L. Gonzalez III Singapore Vll

Introduction Questions about the relationship between participation and social and human development have been around since the ancient Greeks. J. Cohen and N. Uphoff, 1980 Cornell University

More research is needed on the importance of community participation to the sustainability of health care systems. Specifically, different models of participation need to be identified, and the more successful experiences need to be documented. J. Rice, 1990 United States Agency for International Development and World Vision Relief

Yet, despite the widely shared view that participation improves project performance, clear and convincing evidence on the link between participation and project outcomes is surprisingly scarce. Advocates of participation have relied primarily on case studies to document the link between participation and performance. But these are easily dismissed by skeptics because of the small number of cases and the informal testing of the findings. J. Page, 1998 The World Bank

Many social scientists all over Asia and the world are caught up in what seems like a never ending search for ways and means around obstacles that hinder project and program success in developing countries. One of the “miracle cures” that they have been prescribing since the mid-1970s is the use of increased community participation. In broad tenus, community participation implies increasing stakeholder or client involvement in almost all aspects of a project cycle1 1

2 Development sustainability through community participation from the planning and design to the actual implementation and monitoring. With the help of academics and nongovernmental organizations (NGOs), community participation became the virtual panacea of the 1980s. Consequently, the 1990s witnessed bilateral and multilateral development agencies like the Asian Development Bank (ADB), the International Bank for Reconstruction and Development (IBRD/World Bank), the United States Agency for International Development (USAID), which traditionally emphasized the economic, financial, and technical aspects of development projects, slowly began to place more serious concern for a programs social and civic dimensions primarily to increase the likelihood of development sustainability—the continuation of the benefits and activities of a development project beyond donor funding or supervision (See, for instance: UNDP, 1993; World Bank, 1995). At the local government level of developing countries, increased stakeholder participation was encouraged, empowering the community to take responsibility for maintaining a project’s output(s) with less or even no central government support. Some specific examples of these socioeconomic development outputs are: better quality educational opportunities, preventive health care habits, or environmental conservation and preservation consciousness. As a result, concern for community participation intensified in both development research and practice in Asia and the rest of the developing regions in the world. It became imperative for development projects in the 1980s and the 1990s to have a community participation component to ensure sustainability (See Bamberger, 1986; Briscoe and de Ferranti, 1988; Bhatnagar and Williams, 1992). Overwhelming empirical support for this panacea poured in from both researchers and practitioners of social development. The latest international conferences to throw in its endorsement was the 1994 World Bank Workshop on Participatory Development in Washington, DC and the 1995 Social Development Summit in Copenhagen. These conferences and many more have spawned a multitude of published and unpublished papers on issues surrounding community participation. To empirically verify this growing prescription, a computer-aided data mining1 approach w'as utilized in this study to search through the following CDROMs to develop a database of records on these two interesting development concepts. In this era of databases compiled in high-volume hard drives, floppy diskettes and electronic tapes, CD-ROMs, on-line networks and systems, and recently Web-sites, information now abounds on almost any topic or area a research scholar can conceptualize. However, this phenomenal growth of high­ speed access to large-scale information has its pros and cons. For instance, a big advantage of computerization and access to databases is that it gives one an abundant amount of information to gather, process and analyze, making his or her research very exhaustive. But, the amount of information that databases yield can

Introduction 3

be quite overwhelming and unbounded. Given time and resource constraints, a serious challenge facing researchers who wish to take advantage of this type of high-level computer technology is how to reduce the size of the information output from a database search and at the same time be able to maximize the search results. After all, development administration is multidisciplinary in nature, which essentially means influence from a variety of established academic fields and sub­ fields like sociology, political science, management, engineering, health, agriculture, public administration, and others. Consequently, this means sorting through a huge amount of literature in a number of electronically accessible databases. The On-line Library Catalogs accessed represented libraries from the east coast, west coast, and midwest or intermountain west of the United States. They were selected for their geographic representation as well as specialized collections. These library databases were: the University of Utah On-line library system (UNIS), the University of California and California State Universities (MELVYL), the Colorado Association of Research Libraries (CARL) and the Harvard University On-line Information System (HOLLIS). Bilateral and multilateral development institutions diat were accessed included: the United States Agency for International Development (via the USAID Database), the World Bank (via the Bank Reports Bibliography in All-In-One), the United Nations Development Programme, the Organisation for Economic Co-operation and Development (OECD) and the Ford Foundation. Requests for information from the different agencies that specialized in carrying out development administration activities yielded substantive quantitative information only from the USAID and World Bank. An examination of the available library information (e.g. annual reports and publications catalogues) and communications provided by various offices at the OECD, UNDP, and Ford Foundation indicated that these institutions have carried out few direct field projects and activities pertaining to project sustainability. The CD-ROM databases included in the study were: Social Planning, Policy and Development Abstracts (SOPODA), Sociological Abstracts (SA), and Social Science Index (SSI). These databases index and abstract more than 2000 journals and serials on social and health development and other related areas. The search located 591 studies (e.g. published articles, books, government documents, etc.) that dealt with community participation and project sustainability. Figure 1 confirms the growth in concern for these two important development concepts, from only 87 studies and evaluations in 1981-85 to a huge 504 studies in 1986-90. After the search, an in-depth content analysis was used on a more limited 45 documents that represented the trend from the larger data set. These 45 studies

4 Development sustainability through community participation

1990

provided a diverse sample of health and health care-related development projects from Asia, Africa, and Latin America.

Figure 1. Community participation and project sustainability, 1981-90

Introduction 5

Main Objective and Organization of the Book Contrary to widespread expectation, there were also development scholars and practitioners who expressed their doubts about the “miraculous abilities” of this panacea. These studies on development projects from Asia, Sub-Saharan Africa, and Latin America claim that this view is an exaggeration. Hence, they seem to portray the affirmative perspective, i.e. community participation is the much needed factor for success, as a myth. The main objective of this book is to explore these competing views in the following chapters. Chapter 1 is devoted to an examination of the various definitions of both community participation (CP) and project sustainability, the two concepts found to be the ongoing obsession of social science researchers dealing with development studies. A review of the vast and multidisciplinary development literature revealed three general ways of conceptualizing community participation: ( 1) expounding through the means-and-ends approach; (2) using a laundry-list of definitions; and (3) categorizing through an institutional/contextual framework. Similarly, sustainability as a measure of development project effectiveness or success can be defined and operationalized in many different ways, depending on a number of factors. Chapter 2 is a discussion of the two groups of views—affirmative and negative—on whether or not community participation is really essential to development sustainability based on the database search which came up with 45 core studies. It elaborates on the arguments and evidence from a subset of scholars and practitioners who seem to strongly support the conventional thinking about community participation and development sustainability. The chapter also exposes the two sub-groups of negative views that provide evidence that community participation is not always a key factor needed to ensure development success. While discussing both perspectives, die chapter also highlights some of the internal and external factors that have been identified by scholars and practitioners to be equally important to project sustainability. Chapter 3 discusses the influence of the evolving development administration emphases—centralization and decentralization—to health care service delivery in the Philippines. Millions of dollars in technical, financial, and managerial aid from international organizations (e.g., United States Agency for International Development, International Bank for Reconstruction and Development, World Health Organization, United Nations Development Programme, Canadian International Development Agency) have been poured into the Philippines to promote these development-inducing administrative arrangements. In die second section of diis Chapter, the discussion focuses on the experiences of 38 local level development projects and programs that have resulted

6 Development sustainability through community participation

after the shift to a more decentralized health care delivery system. It evaluates these project and programs to determine the significance of community participation to their success. Chapter 4 is an in-depth evaluation of four cases: (1) Matabungkay Population Project, (2) Hanunuo Mangyan Community Health Project, (3) Mindanao Schistosomiasis Control Project, and (4) Nueva Ecija Primary Health Care Project. These four cases were taken from the 38 health care projects described in the previous section and are highlighted in this chapter. These development project experiences are examined to determine the degree of community participation, institutional arrangements, project characteristics, and contextual factors that contributed to their sustainability or nonsustainability. The first two provided support to the affirmative view that community participation is a strong determinant of project sustainability while the last two reinforce the dissenting perspective about community participation’s significance to the development effectiveness. Based on the empirical evidence presented in the previous chapters, the book concludes with a verdict on whether community participation really matters to development sustainability. It also reveals some conceptual and policy constraints on which present and future public health care managers and provider should reflect on.

Research Approach and Data Sources Thirty-eight Philippine health care project studies identified from CD-ROM databases described earlier and actual health care projects from Carino and Associates’ (1982) “A Compendium of Existing Mechanisms for Meeting Health and Related Needs in the Philippines” are evaluated in this study. The researcher had to rely on the databases and the Carino and Associates listing as sources for a representative sample since neither governmental nor nongovernmental agencies have comprehensive listings covering all health care projects in the Philippines. The sample size represents 84.4 per cent of all Philippine health care projects found in the four health and health-allied databases. It also represents 95.0 per cent of the projects listed in the Carino and Associates study. The quality of the sample represents a mix of characteristics from health care projects all over the Philippines. The information regarding rural development participation and sustainability was collected from both “not sustained” and “sustained” projects. The projects were derived mostly from the 1970s and 1980s so that both short-term and long-term sustainability

Introduction 1

could be tested. In addition, the 38 Philippine projects represent the following descriptive characteristics: ( 1) three major geographic island regions of the Philippines (Luzon, Visayas, and Mindanao); (2) three general proponent types (nongovernmental, governmental, and joint sponsorship); and (3) two major project types (integrated and sector specific). These 38 projects represent evaluations and actual studies initiated by the Philippine Department of Health (DOH), Philippine Council for Health Research and Development (PCHRD), Philippine Institute for Development Studies (PIDS), National Economic and Development Authority (NEDA), United States Agency for International Development (USAID), Canadian International Development Agency (CIDA), International Development Research Center of Canada (IDRC), De La Salle University Research Center (DLSU-RC), University of the Philippines’ Colleges of Public Administration, Nursing, Medicine, Social and Community Development, and Public Health, and other local and foreign scholars and institutions. Open-ended questions and a semi-structured questionnaire form were used as the primary instruments to guide collection of detailed information on each projects especially the ones to be used as case studies. Each evaluation form sought to extract the following information from the 38 projects: ( 1) project type, proponent and beneficiaries, and geographic location; (2) goals and objectives of the project; (3) involvement, interaction, and collaboration between staff and the community in planning, implementation, and the sustainability processes of the health care project; (4) project outputs in terms o f human resources, physical constructions, and institution building; (5) project outcomes (the health benefits gained by the community); (6) status of outputs and outcomes after the project terminated; (7) long-term and unintended consequences of the project; (8) number of years used as a start­ up period; (9) number of years the project outcomes and outputs continued after the start-up period; and ( 10) other internal and external variables. Many limitations were encountered in the study. The suitability of the questions and indicators used in the evaluation guide was determined by the amount of information available from previous studies. Some projects had information on specific indicators like records of attendance during planning and implementation activities, minutes of planning and implementation meetings, and results of votes on suggestions during planning and implementation activities. Reasons for the unavailability of these specific types of data were mainly attributed to inconsistent record keeping procedures or absence of records. Open-ended questions were used so that each evaluation would concentrate on extracting participant, observer, and evaluator descriptions, which were categorized according to their

8 Development sustainability through community participation

participation characteristics. As opposed to using highly specific indicators of community participation and development sustainability in each health care project, these qualitative categorizations were used to build an objective picture of the possible causal relationships that might exist between the two concepts under study.

Note *Data mining is a systematic computer-aided technique more commonly utilized in Decision Science and Information Technology to uncover potentially significant patterns and trends from large databases.

1

Operationalizing Community Participation and Project Sustainability

What does community participation and project sustainability mean in the context of development? This chapter seeks to find answers to this basic question by examining the various definitions of both community participation and project sustainability, two concepts found to be a major area of focus among social science researchers dealing with development studies. It is divided into two sections. The first section reviews the vast and multidisciplinary development literature to discover the conceptual and operational underpinnings and meanings of community participation. It organizes these findings into three general ways of conceptualizing community participation: ( 1) expounding through the means-and-ends approach; (2) using a laundry-list of definitions; and (3) categorizing through an institutional/contextual framework. In the second section, a similar systematic computer-aided search was used to sift through the literature to find out the conceptual and operational definitions of project sustainability as a measure of development project effectiveness or success. The second section begins with a discussion on the origins of sustainability as a development focus and how different scholars and practitioners have defined this concept in the light of decentralization and local-level project and program management. This is followed by a more indepth analysis to queries about: what is being sustained, who are responsible for sustaining project outputs and outcomes, and how long is the project supposed to be sustained.

Community Participation in Development Studies

Background Prescribing increased community participation in projects at the local-community level has its roots in the decentralization movement. As advocated by 9

10 Development sustainability through community participation

development experts of the 1980s, decentralization is the institutionalization of more participatory modifications on the traditionally nonparticipatory processes perpetuated by the governmental bureaucracies. Development experts believed that a solution to the dysfunctions associated with planned development through a highly centralized administrative system was to decentralize the functions of bureaucracy. The problem of implementing plans through a centralized development approach led to a call for a more decentralized administrative approach. In one of his studies, Dennis Rondinelli summarized a plethora of arguments for a more decentralized approach to planning and implementation: (1) Decentralization can be a means of overcoming the severe limitation o f centrally controlled national planning by delegating greater authority for development planning and management to officials who are working in the field, closer to the problems. (2) Decentralization can cut through the enormous amounts o f red tape and the highly structured procedures characteristic of central planning and management in developing nations that result in part from the over concentration of power, authority, and resources at the center of the government in the national capital. (3) By decentralizing functions and reassigning central government officials to local levels, these officials’ knowledge of and sensitivity to local problems and needs can be increased. (4) Decentralization could also allow better political and administrative “penetration ” of national government policies into areas remote from the national capital, where central government plans are often unknown and ignored by the rural people or are undennined by local elites, and where support for national development plans is often weak. (5) Decentralization might allow greater representation for various political, religious, ethnic, and tribal groups in development decision making that could lead to greater equity in the allocation of government resources and investments. (6) Decentralization could lead to the development of greater administrative capability among local governments and private institutions in the regions and provinces, thus expanding their capacities to take over functions that are not usually performed well by central ministries.

Community participation and project sustainability 11 (7) The efficiency o f the central government could be increased through decentralization by relieving top management officials of routine tasks that could be more effectively performed by field staff or local officials. (8) Decentralization can also provide a structure through which activities o f various central government ministries and agencies involved in development could be coordinated more effectively with each other and with those of local leaders and nongovernmental organizations within various regions. (9) A decentralized governmental structure is needed to institutionalize the participation of citizens in development planning and management. (10) By creating alternative means o f decision-making, decentralization might offset the influence or control over development activities by entrenched local elites, who are often unsympathetic to national development policies and insensitive to the needs of the poorer groups in rural communities. (11) Decentralization can lead to more flexible, innovative, and creative administration. (12) Decentralization of development planning and management functions allows local leaders to locate services and facilities more effectively within communities, to integrate isolated or lagging areas into regional economies, and to monitor and evaluate the implementation of development projects more effectively than can be done by central planning agencies. (13) Decentralization can increase political stability and national unity by giving groups in different sections of the country the ability to participate more directly in development decision making, thereby increasing their “stake” in maintaining the political system. (14) By reducing diseconomies o f scale inherent in the over concentration of decision making in the national capital, decentralization can increase the number of public goods and services—and the efficiency with which they are delivered—at lower cost (Cheema and Rondinelli, 1983, pp. 1415) (Italics provided).

In order to increase the likelihood of implementation, development experts of the 1970s concentrated their decentralization approach on prescribing ways and means aimed at reorienting the structure and function of

12 Development sustainability through community participation

the governmental bureaucracy as evidenced by Rondinelli’s enumeration above. The anticipated result was increased client-orientedness. This type of decentralization was the same response American public administrators presented during the debureaucratization efforts of the U.S. in the 1930s and 1940s (see Gulick and Urwick, 1937; Brownlow et a i, 1937; and Merriam, 1940). A major reorientation of the structural and functional prescriptions was supposed to make the administrative system more effective in implementing development plans especially at the local community level. The reoriented organizational structure allowed participation in the decision­ making process by field personnel and target beneficiaries. This was assumed to be the key to successful implementation. There are basically four major categories of structural reorientations advanced in the decentralization literature: (1) Déconcentration is “the handing over of some administrative authority or responsibility to lower levels within the central government ministries and agencies”. (2) Delegation “transfers managerial responsibility for specifically defined functions to [public] organizations outside the regular bureaucratic structure, such as public corporations, regional development agencies, and other parastatal organizations”. (3) Devolution is “the creation or strengthening, financially or legally, of subnational units of government, whose activities are substantially outside the direct control of the central government”. (4) Privatization refers to the divestiture of governmental responsibility for functions “either by transferring them to voluntaiy organizations or by allowing them to be performed by private enterprises”. (Rondinelli et a i, 1984, p. 67.) (Italics added.)

The first three pertain to different types of structural bureaucratic reforms used to decentralize whereas the fourth refers to nongovernmental alternative delivery systems (e.g. private voluntary organizations (PVOs), nongovernmental organizations (NGOs), international governmental organizations (IGOs)). It was argued that the use of nongovernmental entities helps alleviate some of the resource inadequacies of the governmental bureaucracy. These non-traditional, non-hierarchical, non-governmental entities were expected by development experts to increase the prospects of project and program implementation because of their simple and flat

Community participation and project sustainability 13

organizational structure, which was conducive to beneficiary involvement in the decision-making procedure. The theoretical descent of process decentralization in development management could be traced to the debate between the Weberian-inspired school of management and the response by organizational humanists. The Weberian-inspired centralized approach was seriously challenged in theory and practice by authors who subscribed to the organizational humanist school of management (e.g., Mayo, 1933; Simon, 1946; Dahl, 1947). Herbert Simon and Robert Dahl criticized the advocates of the classical approach to management for promoting a “scientific” and value-free paradigm of domestic and international administration. Organizational arguments based upon Weber’s bureaucratic model were also criticized by Robert Merton (1952, p. 36) with having the following dysfunctions: (1) Veblen s concept o f “trained incapacity” - this concept refers to that state of affairs in which one’s abilities function as inadequacies or blind spots. Actions based upon training and skills which have been successfully applied in the past may result in inappropriate responses under changed conditions. (2) Dewey s notion o f “occupationalpsychosis” - this basically rests upon much the same observations as Veblen’s concept. As a result of their dayto-day routines, people develop special preferences, antipathies, discriminations and emphases. (3) Warnotte’s view o f “professional deformation ” - this view states that adherence to the rules, originally conceived as a means, becomes transformed into an end-in-itself; there occurs the familiar process of displacement of goals whereby an instrumental value becomes a terminal value (Italics added).

The advocates of the human relations school of management argued that there is no such thing as a rational and value-free approach to management since the interpretations of rationality and values varied from person to person and culture to culture. Structural and functional reforms remained successful only in the short run, because structural and functional reforms played lip service to the human beings inside the organizational charts and boxes. The local culture of the project beneficiaries was always perceived as a hindrance to development instead of a facilitating force of change. These criticisms and shortcomings of logical positivism and Weberian-inspired development administration practices were carried over

14 Development sustainability through community participation

into the new theme of participatory development. It was now time to propose a more radical change. The advocates for a more humanist approach to managing organizations lambasted the “principles” advocated by the Weberian-inspired school of management as mere “proverbs” and an exercise in Simon’s “architectonics” (see Barnard, 1938; Maslow, 1943; Appleby, 1949; Argyris, 1957; Simon, 1957; McGregor, 1960 and 1966; Blake and Mouton, 1964; Herzberg, 1966). The humanist school o f management presented alternatives to the positivist-oriented approaches like management by objectives (MBO), linking pin, quality circles, job redesign, clarity of goals, T-groups, contingency management, motivation techniques, organization development (OD), job enrichment, and participative management (see Follett, 1924; Drucker, 1954; Deming, 1962; Likert, 1967; Mosher, 1967; Sashkin, 1984; Golembiewski, 1978; Ouchi, 1981; Block, 1987; Herzberg, 1990). These techniques were based on the psychology and sociology of the individuals and groups inside organizations. Using these human relations school prescriptions means going beyond the structural adjustments advocated by Rondinelli and other development experts. Ideally, process decentralization should be used together with the structural rearrangements and functional redescriptions described earlier. Utilizing this combined approach insures that the local entities will institutionalize participation combined with a strengthened local resource mobilization in effect leading to greater sustainability at the village community level. Hence, the ultimate goal is to create the appropriate interaction, collaboration, participation, and involvement to complement the reorganized organizational structure. Robert Golembiewski (1985, p. 146) suggested the following specific strategies which he designed for public organizations to adapt in their process decentralization efforts: (1) Process analysis activities, or applications of behavioral science perspectives to understand complex and dynamic situations.

(2) Skill-building activities, or various designs for gaining facility with behaviors consistent with OD values, for instance, giving/feedback, listening, resolving conflict, etc. (3) Diagnostic activities, which often include process analysis, but which may also employ interviews, psychological instruments, or opinion survey to generate data from and for members.

Community participation and project sustainability 15 (4) Team-building, or efforts to increase the efficiency and effectiveness of intact task groups. (5) Inter-group activities, which seek to build effective satisfying linkages between two or more task groups, such as departments in a large organization. (6) Technostructural activities, which seek to build need-satisfying roles, jobs, and structures. (7) Systems-building or system-renewal activities, which seek comprehensive changes in a large organization’s climate and values, using complex combinations of activities enumerated above, and having time spans of 3-5 years on the average. (Italics added.)

Development proponents from donor and recipient countries employed approaches patterned after these more humanist techniques to help in the effective planning, implementing and sustaining of their development efforts. Based on the activities of this period, sustainable development essentially became human development. These behavioral changes were applied not only in the bureaucracy but also in the service delivery field units. The role of the structurally decentralized grassroots units in policy making was increased through community participation and organization schemes. Participation as an institutionalized behavior was assumed to raise the level of commitment by the beneficiaries thus encouraging them to seek ways and means to sustain the project. Both governmental and nongovernmental groups immersed themselves in making their projects people participatory not only in structure but also in process. Definitions A review of the vast and multidisciplinary development literature revealed three approaches to clarifying the meaning and operationalization of community participation at the project level: ( 1) expounding through the means-and-ends approach; (2) using a laundry-list of definitions; and (3) categorizing through an institutional/contextual framework. Means and ends. The first approach clarifies the meaning of community participation through a “means-and-ends framework” (Castillo, 1982; Moser, 1983 and 1989; Lamberte, 1990). This means-and-ends approach enumerates

16 Development sustainability through community participation the arguments on whether community participation is a means (process) or an end (goal in itself). On one side of the debate, a number of development experts argue that community participation is a means to achieving or enhancing project results (see definition of Pearse and Stiefel, 1979). The successful utilization of community participation increases the quality of life in a village community. Baetz, a development specialist from North America, among others, points out that if people are involved in the actual planning and implementation of the project by contributing ideas and resources the task can be better accomplished. The likelihood of failure is also reduced because of community participation. On the other side, a group of development scholars argue in their studies that community participation is an end in itself (see definitions of Lele, 1975 and De Leon, 1982). To these development experts, community participation is consciousness raising and a process that directly improves the quality of life in a village community. C. Moser (1989) reinforces the “end” side of the debate by arguing that, once participation is learned by a community, it can be replicated as an integral part of all future development endeavors. Moser adds that participation may even be incorporated in every individual community member’s approach to life. A third group of development scholars argues that in their evaluations they find community participation both a means and an end. A. Bhaduri and A. Rahman (1981) advocate this perspective in their evaluation of the policies towards community participation in Tanzania, Vietnam, and Ethiopia. Bhaduri and Rahman believe that these countries are moving towards reconciling the arguments of these two extremes by advocating participation both as a process and a goal. In addition, attendees at a Society for International Development (SID)-Kenya Chapter meeting argued that community participation could be both a means and an end simply because community participation as a process eventually results in institutionalized participation (see SID-Kenya, 1989). The means-and-ends approach suggests that community participation has three dimensions: ( 1) a means, (2) an end in itself, and (3) both means and end. For the purposes of specific measurement these three dimensions are not helpful without further operationalization. Laundry lists. The second approach in the development literature expounds on community participation through a “laundry-list of definitions”. This approach starts out with a collection of selected definitions of community participation representing numerous perspectives and time periods. After gathering the definitions from the literature, a process of selection was performed to pick out salient characteristics from each to create one’s own.

Community participation and project sustainability 17

Several studies utilize this approach to develop their operationalization of participation (see Moser, 1989). Though the “means-and-ends approach” is an important starting point in analyzing community participation, the researcher believes that the use of the “laundry-list of definitions” provides a better organized and more specific operationalization of the concept. The succeeding application of the laundry-list framework illustrate this argument. As stated earlier, the laundry-list framework begins with a group of selected definitions of community participation coming from various perspectives and time periods. Herewith is a list of community participation definitions that the researcher compiled from the 1973-1989 rural development literature:1 Community participation is considered a voluntary contribution by the people to one or another of the public programmes supposed to contribute to national development but the people are not expected to take part in shaping the programme or criticizing its contents (Economic Commission for Latin America, 1973, p. 63). Community participation means to sensitize the people and, thus, to increase the receptivity and ability o f rural people to respond to development programmes, as well as to encourage local initiatives (Lele, 1975, p. 9). Community participation is the organized efforts to increase control over resources and regulative institutions in given social situations, on the part of groups and movements of those hitherto excluded from such control (Pearse and Stiefel, 1979, p. 8). Popular participation in development should be broadly understood as the active involvement o f people in the decision-making process in so far as it affects them (Uphoff and Cohen, 1979, p. 47). Participation includes people’s involvement in decision-making processes, in implementing programmes ... their sharing in the benefits of development programmes, and their involvement in efforts to evaluate such programs (Lisk, 1981, p. 3). Participation is considered to be an active process, meaning that the person or group in question takes initiatives and asserts his/her or its autonomy to do so (Rahman, 1981, p.146).

18 Development sustainability through community participation Community involvement means that people, who have both the right and the duty to participate in solving their own health problems, have greater responsibilities in assessing the health needs, mobilizing local resources and suggesting new solutions, as well as creating and maintaining local organization (World Health Organization, 1982, p. 35). In a review of World Bank development projects, Samuel Paul inferred that community participation is a process by which beneficiary groups (people whom the project is expected to serve) actively influence the direction and execution of projects with a view to enhancing their own well being (Paul, 1987b, p. 20). Participation means the contribution o f beneficiaries to the decisions or work involved in the projects (Finsterbusch and Van Wicklin, 1989, p. 575).

From a review of this laundry-list of definitions, various patterns can be inferred. For purposes of analysis, let us categorize these approaches in terms of: (1) specific activities, (2) definition of participants, and (3) strategies suggested. The first three interpretations (ECLA, 1973; Lele, 1975) pointed to planning activities (e.g. identification of problems and prioritizing action) as the concentration of community participation in the early 1970s. The next five interpretations (Pearse and Stiefel, 1979; Uphoff and Cohen, 1979; Lisk, 1981; Rahman, 1981; WHO, 1982) add implementation activities (e.g. management and administration of benefits or services) as another area of concern aside from planning activities. This was true from the late 1970s to the early 1980s. The last two interpretations (Paul, 1987; Finsterbusch and Van Wicklin, 1989) bring out sustainability activities (e.g. establishment of physical facilities and organization of beneficiaries) as another area of participation aside from the planning and implementation activities.2 The trend here among the definitions randomly selected is from a general identification of these actors to more specific interpretations. From the ECLA to the WHO definition, the actors in participation are interpreted as people in general. The interpretations get more specific in the Paul (1987a) as well as Finsterbusch and Van Wicklin (1987 and 1989) definitions. These development experts identify the actors in participation as the community or project beneficiaries. The “how” trend in these ten definitions is from a passive to a more active type of community participation. The first three definitions (19731975) are the most passive among all the ten definitions because they call for mere “voluntary contribution”, with people not expected to take part in the

Community participation and project sustainability 19

direct shaping of policy or program. The succeeding interpretations (19791989) provide more active definitions, since they argue for a shift from mere voluntary contribution to control of resources (Pearse and Stiefel, 1979), active beneficiary involvement (Uphoff and Cohen, 1979; Rahman, 1981; WHO, 1982), and direct influence in the decision-making (Paul, 1987a and 1987b; Finsterbusch and Van Wicklin, 1989). The laundry-list approach is still vague on examples of specific community participation behavior, activities, benefits, and services. These shortcomings are the motivation to develop another approach to operationalizing this concept. Institutional-contextual framework. A third approach used to make community participation measurable is a “who, what and how framework”. Unlike the previous nonstructured laundry list, this enhanced version breaks down community participation into three more organized and detailed dimensions, each carefully operationalized. The earliest advocate of this type of operationalization was Robert Chambers (1974). Building on the analytical framework provided by the laundry-list approach and based on his hands-on evaluations of rural development projects in East Africa, Chambers modified the traditional questions into a “who, what institutions or channels and what objectives or functions” analytical framework. The who and what institutions of Chambers were field staff, development committees, and beneficiary groups. The what objectives or functions were programming and implementation, field staff management, evaluation, local participation procedures, rural research and development, and plan formulation. Chambers’ early work was followed by Cohen and UphofFs (1977) own newer version of the institutional/contextual framework which broke down community participation into three specific dimensions—what kind of participation is taking place, who is participating, and how participation is being conducted. In differentiating the Chambers with the Cohen and Uphoff operationalizations, the researcher believes that Chambers’ second dimension is similar to Cohen and Uphoff s first dimension. In addition, Chambers two other dimensions do not seem to prescribe the degree of specificity which Cohen and Uphoff s two other dimensions demand. In the comprehensive review of the rural development participation literature, no other study offered the same comprehensive character as these two works (especially Cohen and Uphoffs). In the 1980s, operationalization frameworks from the rural development literature took off from these same “who, what, and how” frameworks. This made community participation a more measurable concept

20 Development sustainability through community participation

for analysis as either an independent, dependent, or even an intervening variable (see Castillo, 1983; Finsterbusch and Van Wicklin, 1987).3 One could argue that the laundry-list approach presented a higher degree of specificity and organization compared to the means-and-ends framework for operationalization. Based on this it can be argued that the Chambers-Cohen-and-Uphoff-pioneered institutional/contextual approach provides the highest degree of specificity and organization among the three frameworks discussed here. Cohen and UphofFs operationalization of participation has the following contextual characteristics: (1) locus of analysis was on projects at the national level; (2) focus of analysis was agriculture; and (3) geographic area was Ethiopia. What kinds o f community participation took place? According to Cohen and Uphoff, there are four major kinds of participation in project cycles: (1) participation in decision-making; (2) participation in implementation; (3) participation in benefits; and (4) participation in evaluation (1980, p. 219). The researcher believes that Cohen and UphofFs operationalizations are inappropriate for the context of this study, and so he has developed the following cycle of rural development activities, which have three general groups of activities: planning, implementation, and sustainability. These three general groups of activities are further broken down into the following: (1) Participation in planning activities—identifying the problem; determining and prioritizing action, benefits and services; and selecting leaders and personnel. (2) Participation in implementation activities—management and administration of benefits, services, action; training of staff and other personnel; and project monitoring and evaluation. (3) Participation in sustainability activities—institution building, which is the establishment of the physical infrastructure (e.g. clinical facilities) and organization of beneficiaries into action groups (e.g. cooperatives or associations); creation of cost-recovery mechanisms or external supplements; and the setting-up of internal and external linkages (community level to state level).

These modifications to the Cohen and Uphoff operationalization framework accommodated recent trends (e.g. sustainability) in the rural development literature after the publication of their study.

Community participation and project sustainability 21

Who participated? In contrast to the four categories used by Cohen and Uphoff, i.e. local residents, local leaders, government personnel and foreign personnel, the researcher divided the “who” in participation into two main groups (proponents and beneficiaries) and several subcategories. The proponents are the donor personnel, e.g. governmental (central, provincial, municipal, local), nongovernmental (university, church, private voluntary group), and expatriate (U.S., Asian, European). Governmental personnel are those assigned to the project area for a period of time. Government personnel are also political appointees or career civil servants. Political appointees and civil servants were selected from within the community, municipality, province, or region. They may also have come from outside the community, municipality, province, or region. Nongovernmental and expatriate personnel may be administrators or regular employees who reside and work at the project area. In the case of academic or research nongovernmental personnel, these may be data collectors, researchers, or observers (participant and nonparticipant). The beneficiaries were subdivided into two groups: the direct and indirect beneficiaries. The direct beneficiaries of the project were the community leaders (both formal and informal) and community members (men, women, children, elderly, and handicapped). Because health care services are common goods, community members benefit from the services and activities (eg. immunization and sanitation) whether they avail themselves of these benefits or not. The indirect beneficiaries of the project are scholars and research groups that benefit from the lessons learned from the project. How did participation take place? What are the different characteristics or manifestations of participation? In accordance with this framework, community participation can be divided into the following institutional/contextual dimensions: organizational orientation (top to bottom or bottom up) and degree of interaction (passive or active). Organizational orientation. Project initiatives which come from the national level down to the village level are labeled top-to-bottom participation. National-level initiatives originate from politicians, bureaucrats, or foreign personnel. Centralized decision-making is a main feature of top-to-bottom participation. A main assumption in top-to-bottom participation is that policy makers at the central offices assume they know what is best for the communities at the local level, since these people are highly educated and highly trained. Specific descriptors used to describe top-to-bottom organizational orientation include strict ranking of duties and responsibilities, tall hierarchic arrangement of line and staff personnel, right-side-up pyramid

22 Development sustainability through community participation shape, and use of blueprint and cooptation methodologies in field implementation. Bottom-up participation utilizes more village-level and field-worker inputs and initiatives. Bottom-up participation uses upward linkages mostly for consultation and coordination. Decentralized decision-making is a main feature of bottom-up participation. Contrary to the assumption of top-tobottom participation, bottom-up participation assumes that people at the lower levels should actually have a larger role in creating policy which directly affects their welfare as beneficiaries. Specific descriptors of ideal bottom-up organizational orientation include flexible and adaptive hierarchy, use of project teams, open lines of communication, and upside-down pyramid form. Advocates of bottom-up participation argue for the use of a learning process instead of a blueprint methodology (Korten, 1984; Mayfield, 1985a and 1985b; White, 1987). Degree o f interaction. Passive participation is usually manifested in discussions or decision sessions. The beneficiaries are present during various meetings or discussions, but their involvement, interaction, and collaboration do not carry as much weight as the proponents’ ideas or the preconceived plan. Passive participation stems from two assumptions. First, proponents assume that their role as experts is to teach the beneficiaries the solutions to their problems. Second, beneficiaries assume that their role is to be receptive and attentive to the suggestions of the proponents (see Korten, 1980 and 1984; Mayfield, 1985a and 1985b). Active participation in rural development activities is manifested in consistent beneficiary and proponent interaction, involvement, and collaboration in discussions and on-the-spot decision-making. Discussions usually come in two forms: formal meetings and informal sessions. Both involve brainstorming, feedback gathering, and confrontational exercises which are conducted in a systematic decision-making way. The first step in the systematic decision-making process is the gathering of suggestions. The second step is the raising of concurring or dissenting opinions about these suggestions. The last step is the making of the decision (or melding of decisions) regarding the issue, activity, or policy through a voting process or any form of consensus-building procedure. On-the-spot or situational decision-making utilizes a contingency process wherein democratically selected personnel make decisions on an issue that needs an immediate response. Sometimes an unscheduled meeting of core decision-makers is called for in emergency situations. In active participation, as much as possible the ideas and suggestions of both proponents and beneficiaries are given equal consideration after a

Community participation and project sustainability 23 process of compromise and consensus. Active participation assumes that both beneficiaries and proponents are contributors to the decision-making process. The ideal is to have all parties concerned be asked for input on important decision situations (see the individual works of ther following PDM scholars: Argyris, 1967; Alutto and Belasco, 1972; Conway, 1984a; Argyris et al., 1985; Bacharach et al., 1990). Methodological process. As opposed to the institutional/contextual model, which assumes that the project beneficiaries are mere objects to be studied, the participation process-oriented framework goes into another area of the methodological process, which considers the perceptions of the project beneficiaries themselves. In the development literature, methodological process is usually discussed as two types: blueprint process and learning process. The first group of rural development participation methodologies relates to what are called blueprint processes. The goal of blueprint processoriented methodologies is to provide action and change information for the project proponents to use. This is accomplished by encouraging the beneficiaries and proponents to participate in providing data and information for use in creating the right policy. The proponents assume that the involvement of the beneficiaries in these planning related activities will facilitate project implementation and sustainability. The role of the beneficiaries in decisions and actual work at the implementation and sustainable activities is minimized because project proponents perceive these areas to be too sophisticated for untrained persons to understand. The blueprint process in the social sciences is influenced by the experimental design of the hard sciences. According to users of this approach from engineering and the hard sciences, the methodology involves a systematic and rigorous data-collection process. The testing of a research hypothesis is done in a careful step-by-step and logically planned manner. Moreover, the experimental design utilizes an experimental and a control group in its evaluation. Statistical and mathematical formulas are common analytical tools in experimental research. Experts in the social sciences thus seek to replicate the rigor and clarity of the approach and the reliability of the instruments claimed by experts in the fields of engineering and hard sciences (see Bautista and Go, 1985; Mead, 1988). Another group of blueprint process-oriented strategies is quasiexperimental approaches. As implied by the prefix quasi-, these methodologies lack the requirements of experimental designs but are structured in an almost similar fashion. Just like the experimental approaches, quasiexperimental approaches use field research designs, reliable

24 Development sustainability through community participation

instruments, and quantitative analysis. Some specific quasiexperimental approaches are cross-sectional or correlational analysis, panel studies, and trend analysis. Correlational analysis involves a survey of beneficiary and proponent opinion. Panel studies use a series of cross-sectional studies based on the same beneficiaries and proponents over a period of time. Trend analysis accounts for phenomena shifts over time. A strong philosophical influence on blueprint process methodologies was the logical positivist school. According to Pablo Latapi (1988), these were some of the arguments in support of quantification and “scientific rigor” from practitioners of the logical positivist paradigm: (1) The purpose of science is the increase of knowledge; knowledge is useful for predicting and explaining events for the purpose of controlling them. (2) Reality is objective; it exists independently from observation. Scientific grasping of reality requires measures which prevent spurious influences that distort facts. Research must be objective. (3) Scientific research requires a method. Although there are different research methods and techniques, the research process always requires a theoretical framework, hypothesis to be tested, data collection, interpretation, revision of the hypothesis, and reproducibility of findings. Only then can the accumulation of knowledge take place.45 (4) Evidence and findings must be expressed, whenever possible, in mathematical terms. Even the assessment of qualitative realities must be expressed by quantitative indicators; otherwise scientists are exposed to subjective biases. (5) Research is a specialized activity reserved for trained professionals.

According to some proponents of this methodological process, one advantage of blueprint approaches is their highly sophisticated analytical outcomes. In the academic community the outcome of a project utilizing a predominantly blueprint process is generally written up for academic publications or seminar presentations to fellow scholars. An example o f a blueprint process applied to development research is policy analyses. Policy analyses are generally projects commissioned to a professional researcher or consulting company by a beneficiary group, governmental entity, or international organization. The beneficiaries group or client organization

Community participation and project sustainability 25

select a problem area based on their immediate policy need. Then a researcher or consulting company designs an approach with the beneficiary or client organization to match the problem. Implementation and sustainability activities are supervised and monitored by the researcher or consulting company. The outcome is a carefully prepared paper filled with figures and survey results that are used for the purpose of justifying legislation or administrative policy. Some development advocates in the field of sociology argue that the use of blueprint process approaches (e.g. survey-interview) makes rural investigation more scientific (see Sanderson, 1927; Taylor, 1937 and 1940; Lively, 1943; Brunner, 1946).4 The second group of development participation methodologies is learning process approaches. The goal of learning process methodologies was the involvement of both the people who are the beneficiaries of the project and the project proponents in a joint endeavor addressing the problem (Anyanwu, 1988). When handled properly, learning process-oriented approaches seek to achieve the following important implementation and sustainability characteristics: (1) research that is the gradual discovery of new knowledge (for both beneficiaries and proponents) (Hall, 1984); (2) action as a component of the process that moves from practice to reflection and from reflection to practice (Fals-Borda, 1987); and (3) education, because the beneficiaries gained a better understanding of facts and improve their capacity for reflection and analysis (Latapi, 1988 and Salmen, 1987). Learning process approaches came about as an alternative to the positivist paradigm of the philosophy of the sciences and its application to social research approaches (Latapi, 1988). To a certain extent, learning process approaches try to reconcile the arguments of the philosophical debate between advocates of logical positivist-oriented approaches and its critics with an integrated methodology that takes from both schools (see Okamura, 1985). The integration of beneficiary and proponent collaboration into all phases of rural development emerged as a reaction to the failures of blueprint process approaches to bring about lasting development change in the rural community (Fernandes and Tandon, 1981). In learning process methodologies, the problem area is chosen by the proponent and beneficiaries based on an immediate issue facing the village (e.g. inadequate sanitation measures). The integral component of learning process approaches is the use of archeology’s archival research (Alampay, 1985), communication’s content analysis (Budd et al., 1967; Berelson, 1971), history’s oral history (Mason and Starr, 1973; Davis et al., 1977; Foronda, 1979), linguistics

26 Development sustainability through community participation ethnolinguistic method and case histories (Goodenough, 1956; Samarin, 1967; Gonzalez, 1973), psychology’s process documentation and group process diagnosis (Bales, 1950; De Los Reyes, 1983; Chiong-Javier, 1985), education’s participatory research and participatory action research (Hall, 1979; Callaway, 1980), anthropology’s ethnographic research and cultural anthropology (McCall and Simmons, 1969; Spradley 1980), management’s organization development and participatory action science (Dachler and Wilpert, 1978; Dickson, 1982; Argyris et a l, 1985), sociology’s participant observer (Meehan and Beal, 1977; McCall, 1984), and rural development’s pedagogical analysis and social learning (Freire, 1969 and 1972; Korten, 1980 and 1984; Mayfield, 1985a). Simple quantitative techniques are used to reinforce the findings of these learning process approaches. Quantitative techniques in learning process approaches integrate less sophisticated experimental and quasiexperimental analytical tools, e.g. computer-assisted analysis (CAA), descriptive statistics, simple inferential statistics, probability analysis, and research measurements (see Klieger, 1984; Achen, 1986; Meier and Brudney, 1987; Finsterbusch et al., 1990). Due to the involvement, collaboration, or interaction of both the project proponent and client-beneficiary in the planning, implementation, and sustainability of the development project, knowledge gained is not a monopoly of the project proponent. Change or action steps towards the problem are immediately implemented as a joint activity. Change in the blueprint process methodologies depends upon the response of persons reading the report (publication) or listening to the presentation or proponent initiative. Hence, fellow scholars, bureaucrats, or consultants are the ones benefiting from the blueprint process analysis. Beneficiaries have to twist the arms of politicians and bureaucrats to see changes. This develops a gap between the written report and the actual delivery of results. The lessons learned from the inadequacies of the blueprint processes stimulated a number of development scholars to further refine the concept of participation (Cohen and Uphoff, 1977; Castillo, 1983; Korten and Klauss, 1984). This led to the prescription of learning process approaches to rural development. Learning processoriented approaches are conceptualized to bring about genuine involvement of the people. Because of the influence of learning process approaches, the goal of participation began to shift from mere consciousness-raising in planning and implementation to actual capacity building and concern for self­ sustainability (see Honadle, 1981 and Rice, 1990). Some advantages of learning process approaches over blueprint process approaches are the following: (1) the shift of the location of research from metropolitan and nation-state perspectives to the village communities of

Community participation and project sustainability 27

the developing world; (2) the shift from expatriate to local researchers; (3) the increased involvement of untrained persons in professional roles; (4) the increased interest in making research accessible to decision makers; and (5) the increased involvement of the poor and exploited in the research process itself (Hall, 1984). Despite what seems like an overwhelming endorsement of learning process strategies, there are still some dysfunctions inherent in these approaches. These dysfunctions are the following: multiple interpretations o f “participation” by the local culture (Alfiler, 1983a); role of the professional researcher, project consultant, or project proponent still too strong (OECD, 1975); research techniques still too advanced for adults who have had little schooling (Latapi, 1988); and criteria for the selection of compatible quantitative and qualitative research techniques still unclear (Latapi, 1988).

Development Project Sustainability Background

At the macro level, attention to the development issue of sustainability peaked only in the 1980s although rhetorical concern could be traced as far back as the 1960s. In 1961, after the successful reconstruction of their war ravaged economies, a group of European nations decided to continue their mutual interdependence at rebuilding and at the same time assist the other parts of the world that remained undeveloped and underdeveloped. These nations established the Organisation for Economic Cooperation and Development (OECD) and Article I of the OECD Convention emphasized the direction of their policies: to achieve the highest sustainable economic growth and employment and a rising standard of living in Member countries, while maintaining financial stability, and thus to contribute to the development of the world economy (Italics added).

The OECD’s use of the term “sustainable development” in the 1960s, however, was based on a more planned development approach which assumed proper planning procedures and reorganization of governmental system were the key to development success. The OECD’s actual application of sustainability in their rural development programs was also delayed by their initial emphases on planning-orientedness to implementation-orientedness.

28 Development sustainability through community participation

The researcher’s evaluation of OECD supported development projects indicated that it was not until the mid-1980s that the OECD sought to initiate actual sustainable development programs that targeted the less developed countries as part of their global strategy. One reason for the OECD’s shift to a more active concern for this development issue could have been the findings and recommendations of the 1985 Brundtland Conference, a meeting of international representatives to the World Commission on the Environment and Development (1987).5 Since then, many individuals and institutions now consider the importance sustainability in any process of rural development. Another development institution that shifted its concern from a planning perspective to a more sustainable development outlook was the International Bank for Reconstruction and Development (IBRD) or World Bank. Bank President A. W. Clausen presented a lecture in 1981 entitled “Sustainable Development: The Global Perspective’’. In his talk, Clausen strongly emphasized the need for the Bank to study global resource management as the issue of the 1980s (IBRD, 1986). Since then, the 1980s became known as the decade of environmental and ecological concern for issues like the ozone layer, oil spills, nuclear disasters and mass deforestration. These issues went beyond the business of a few developed countries (e.g., United States, Great Britain, Australia) to become a global affair. Numerous nonprofit international organizations specializing in environmental and natural resources were formed as a result of this new issue. Some of these organizations included the World Resources Institute, Sierra Club, Greenpeace, Zero Population Growth, and Audubon Society. These environmental organizations tried to address the sustainable development question: How can societies meet human needs and nurture economic growth without destroying the natural resources and environmental integrity that make sustainable prosperity possible (World Resources Institute, 1991)? Thus, the goal of development studies and application shifted from planned and implementable development to sustainable development—with a more long-term and global perspective. Sustainable development sought to respond to the following shortcomings of implementable development: (1) a large majority of the projects and programs implemented in the 1960s and 1970s seemed unable to create long-term benefits or institutions that would last beyond direct donor involvement; (2) many less-developed countries appeared to be locked in a vicious cycle of economic decline, increasing poverty, and environmental degradation in spite of the tremendous amount of foreign aid given; and (3) the world as a whole now seemed to be facing both

Community participation and project sustainability 29

financial and ecological problems unprecedented in scope and seriousness (Arnold, 1989). The pursuit of a more forward looking, human enhancement, and global ecology yardstick was strengthened in both published researches by rural development scholars (see Honadle and Van Sant, 1985; Morss and Gow, 1985; Chambers, 1987; White, 1987; Ponce et al., 1989; Bossert, 1990; Ostrom et al., 1990) and field projects by rural development organizations (e.g. CIDA, USAID, IBRD, UNDP, OECD, Chemonics, Ford Foundation (see Mondot-Bemard and Labonne, 1982; Brown, 1988, MacNeill, 1989; Rees, 1989; Davis and Ackermann, 1991). Initial results of both the academic research and field studies presented evidence that not all implementable activities continued to provide benefits beyond the initial start­ up period. The need to shift goals was therefore imperative. In the preliminary search for documents on this new orientation of development research and practice, the study found two development journals that carried special editions—based upon a post-Brundtland conference— which emphasized this issue from both the academic and practice-oriented sectors. The first development journal was Futures. This journal centers on planning and forecasting. In 1988, a special issue of Futures (Redclift and Pearce, 1988) was devoted primarily to “sustainable development”. This issue had six published articles from a variety of disciplines, i.e. sociology, economics and ecology. The articles expounded on the sustainable development challenge of maintaining project benefits beyond implementation. David Pearce in the first article argued that the stock of “natural capital”6 needs to be increased rather than reduced, if social and economic goals are to be achieved. This was followed by Richard Norgaard’s article that stressed the importance of a holistic view of development which means looking more at human and environmental interactions. Peter Nijkamp and Frits Soeteman argued in the third article for a re-examination of existing agricultural and land use policies that are inconsistent with the coevolution of the environment and development. Unlike Pearce and Norgaard, Michael Redclift argued in the fourth article for a political economy approach which compares and contrasts societies on the basis of the use to which they put the environment. In the fifth article, G. Conway and E. Barbier argued for an agricultural system that would assess development with an equal concern for environmental losses. In the last article, Bernhard Glaeser re-emphasized the need for a more holistic context of sustainable development that gives more attention to human ecology.

30 Development sustainability through community participation After reviewing the six articles in this special issue of Futures, the researcher discovered this common theme—a more holistic approach to rural development that takes into consideration human ecology and the environment. This was clearly summarized in Bernhard Glaeser’s argument for a more holistic policy which is interpreted to mean that development policy should not only concentrate on the natural resources and agricultural sector but also expand to other areas. This is why Glaeser argues for holism which integrates into the equation industry, irrigation, public works, micro­ enterprises, and health care as part of the natural and socio-cultural environments of the development system. The second academic journal was Development. This journal is the official publication of the Society for International Development (SID). Beginning in 1981, a few development scholars contributed articles on sustainable development. There were four Development articles on sustainable development from 1981-1988. Twenty-five published works were added to this number in 1989. The Development articles prior to 1989 dealt with either the issue of self-sufficiency or self-reliance. This concentration on issues of self-sufficiency culminated in the publication of a 1989 special edition of Development (Linder, 1989) entitled “Sustainable Development: From Theory to Practice”. Like the articles in Futures, the Development articles provided readers with multiple perspectives on sustainable development. Each discipline interpreted the Brundtland mandate depending on one’s area o f specialization and the ability of their discipline to contribute to this global concern. For example, the business administrators concentrated on sustainable financial capacity; the agronomists concentrated on sustainable agriculture; the environmentalists concentrated on sustainable environment growth; and the economists concentrated on sustainable economic development. Several scholars and practitioners in the Development special issue brought to the forefront the neglected issue of a more humanist approach to multilateral rural development. These development specialists argued that sustainable development should not be a strategy based on the traditional notions of acquiring more material wealth. Sustainable development should be equated with human development which means increasing the capacity of rural masses to shape their own destiny. At the micro level, development scholars and practitioners interpreted this call for more humanism to mean a call for increased collaboration and involvement between beneficiaries and proponents in the design, implementation, and maintenance of programs or projects. This essentially linked sustainable development to calls for increased decentralization and

Community participation and project sustainability 31

community participation. Thus, sustainability as a development focus at the project and program levels was bom. Definitions

Based on their numerous field evaluations, the USAID has identified nine components of a central system around development projects or programs. The nine components are: (1) the health condition before the health care project began; (2) the goals and objectives of the project; (3) the inputs in funds, materials, and technical assistance provided by the project; (4) concurrent activities at the national government and international donors; (5) the implementation process of the health care project; (6) project outputs in terms of human resources, physical constructions, and institution building; (7) project outcomes (the health benefits gained by the community); (8) the status of outputs and outcomes after the project terminated; and (9) longer-term and unintended consequences of the project (Bossert, 1990, p. 1016). Bossert (1990) increased the sustainability system’s number of components and degree of complexity based on his own evaluation of African and Central American health care projects. Bossert’s sustainability system was organized into two main headings: contextual factors and project characteristics. According to Bossert, contextual factors are relatively fixed and not subject to the control of the project proponents and managers. He identified the following nine contextual factors: (1) natural disasters, (2) political factors, (3) donor-host country bilateral relations, (4) socio-cultural factors, (5) economic factors, (6) private sector, (7) implementing institution, (8) donor coordination, and (9) national commitment. In addition, Bossert argued that there were variables which could be altered and controlled by the project proponents and managers. He labeled these factors project characteristics. He enumerated the following six project characteristics: project negotiation process, institutional and managerial aspects of the project, financing, content aspects, community participation, and project effectiveness. Hence, in addition to community participation, any of these variables present in the system around each project may be critical to sustainability. The following are definitions of sustainability gleaned from the development literature:7 Honadle and Van Sant (1985) suggest a five-year period after the start-up project has ceased before an evaluation is conducted to determine the magnitude and nature o f the inheritance ¡eft behind (p. 2).

32 Development sustainability through community participation Based on an extensive review of project evaluations, Cassen et al (1986) determined that sustainability is when “much more attention has been given to the life o f the project beyond the time o f the donors' involvement”. A development project is sustainable when it is able to deliver an appropriate level o f benefits for an extended period o f time after major financial, managerial, and technical assistance from the external donor is terminated (USAID, 1988, p. 3). The CCCD sustainability-strategy document defines a sustained project as one in which: “health behavior and status improvements, as well as essential project activities, continue after the end o f USAID funding and technical assistance; and all local currency and some foreign-exchange costs are assumed by governmental or private/personal sources (rather than by other donors) after USAID funding ceases” (Bossert and Stinson, 1988, p. 1). In a study that integrates hands-on evaluations of five previous studies at projects in Africa and Central America (Bossert et al., 1987; Bossert et a l, 1988; Adamchak et al., 1989; Dunlop et al., 1990; and Mock et al., 1990), Bossert (1990) defines sustainability as the continuance o f activities and benefits generated by the donor and community at least three years after the end of the project (p. 1016).

These definitions reveal three important dimensions of health care sustainability: (1) what was being sustained; (2) who were the actors responsible for sustaining the project; and (3) for how long was the project supposed to be sustained. What Was Being Sustained? There were two main categories of “what” to sustain health care outputs: activities, services and benefits, and health care outcomes (behavior modification and status changes). Moreover, health care projects may have individual goals (e.g. family planning) or integrated objectives (e.g. a package of community organization, preventive, promotive, and curative care). Health care outputs. The basic health care activities for increasing sustainability include: training of health workers from nonprofessional village health workers to professional sanitary engineers; construction of infrastructure, from clinics to sanitary facilities; technical, managerial, and

Community participation and project sustainability 33

financial capacity; and organization of community members, from users’ associations to health financing cooperatives. The basic health care services and benefits for increasing sustainability include: consultation and referral, immunization projects, mental care, rehabilitation services, family planning, malaria and other disease control, food and nutrition planning, sanitary and water projects, maternal and child care, and dental care. Health care outcomes. The basic health care behavior modifications that require sustainability include: personal hygiene, community cleanliness, and the active support of community-based organizations. The specific health care status changes that require sustainability include decrease in mortality, increase in life expectancy, and decrease in malnutrition cases. Who were Responsible fo r Sustaining Health Care? The actors who were found to be responsible for sustainable health care projects can be divided into two groups: proponents and beneficiaries. The proponents are the donor personnel e.g., governmental, nongovernmental, and expatriate. Governmental personnel are those assigned to the project area for a period of time. Governmental personnel could be political appointees or career civil servants. They could come from the health or nonhealth agencies. Political appointees and civil servants could be selected from within the community, municipality, province, or region. They could also be selected from outside the community, municipality, province, or region. Nongovernmental and expatriate personnel could be administrators or regular employees who reside and work at the project area. Academic or research nongovernmental personnel these could be data collectors, researchers, or observers (participant and nonparticipant). Just as in development participation, project beneficiaries could further be subdivided into two main groupings: the direct beneficiaries and the indirect beneficiaries. The direct beneficiaries are the community leaders (both formal and informal) and community members. Indirect beneficiaries are businesses and nongovernmental, governmental, and international organizations that may have interests allied with the health project. These indirect beneficiaries could provide essential external linkages critical to the sustainability of the health care project.

34 Development sustainability through community participation How Long was the Project Supposed to be Sustained?

Three of the five sustainability definitions (Cassan et a l , 1986; USAID, 1988; Bossert and Stinson, 1988) do not mention a specific measurable time frame to be used in determining the sustainability of a development project. Instead their suggested measure of sustainability is summed up by the USAID definition “an extended period of time after major financial, managerial, and technical assistance from the donor is terminated”. Two of the five definitions suggested specific time frames. Bossert (1990) who evaluated USAID-sponsored African and Central American projects, determined that the length of sustainability should be at least three years after the project ended. Honadle and Van Sant (1985) suggest a fiveyear period after the start-up project has ceased before an evaluation is conducted to determine the magnitude and nature of the inheritance left behind (p. 2). Unlike the USAID evaluations in Bossert’s study, Honadle and Van Sant’s timeframe was not based on an actual evaluation of projects for the prescribed period of time after donor assistance.

Summary of Findings This chapter demonstrates that both community participation and project sustainability are development concepts that have multiple meanings which have evolved over the years. They also draw conceptual influences from other development emphases like decentralization and implementation. Thus, community participation and project sustainability can be operationalized in many different ways, depending on a number of contextual factors. Aside from the definitional aspect, one must be aware that community participation comes in varying degrees of client or beneficiary involvement (from passive to active). Additionally, the literature reviewed shows that scholars and practitioners have used a vast array of implementing strategies, organizational and institutional orientations, and methodological approaches. This is the same case for project sustainability, which has increasingly become a favorite measure of development effectiveness or success. However, despite these differences they all seem to agree on some general points. Realistic outputs and outcomes must be determined from the beginning and fine-tuned along the way. All stakeholders, from both the proponent side and beneficiary side, must be made aware of their respective responsibilities. More importantly, short-term and long-term expectations of all the stakeholders must be clarified from the start. The succeeding discussion evaluates the blending of these two

Community participation and project sustainability 35 development concepts— increased community participation as the ideal process (or means) and sustainability as the desired goal (or measure of effectiveness and also success).

Notes !A11 the italics in these lists of definitions were provided by the researcher to highlight the participation focus of each. 2This fact is probably not very evident in the Finsterbusch and Van Wicklin definition provided here. An examination of the actual arguments of the study better supports this assertion. 3Finsterbusch and Van Wicklin provided an input-output framework in their operationalization of project effectiveness and participation. This conceptual approach still paralleled the institutional/contextual framework inspired by Chambers, Cohen and Uphoff. 4This logical positivist-based argument has been criticized by another group of development sociologists who argue for more humanistic and qualitative approaches to rural investigation. For the latest investigations about the arguments on both sides of the methodological issue and the shifting paradigmatic debates, see Picou et al. (1978 and 1990), Bealer (1990), Falk and Zhao (1990), and Harper (1991). 5This Commission was created in December 1983 by the United Nations General Assembly. The Commission was later known as the Brundtland Commission named after Gro Harlem Brundtland the Prime Minister of Norway and Chairman of the World Commission on Environment and Development. The Commission released its report of findings in 1985. This study considers the Brundtland Conference an important benchmark for this study because it subdivided sustainable development activities into two categories: (1) academic and nonacademic activities that were accomplished five years before the conference or pre-Brundtland (1981-1985) and (2) academic and nonacademic activities that were conducted five years after the conference or post-Brundtland (1986-1990). Natural capital means the stock of environmental assets (or natural resources) which have not received human development, e.g. water, forest, rivers, soil quality and other biomass. On the other hand, human-made capital are machinery, infrastructure, factories and technology. 7A11 the italics in this list of definitions were provided by the researcher to highlight the sustainability focus of each.

2

Does Community Participation Really Matter to Development Sustainability?: Competing Views and Evidences

This chapter discusses the responses and evidence provided by two groups of views—affirmative and negative—on whether or not community participation is really essential to development sustainability based on the database search which came up with 45 core studies. It elaborates on the arguments and evidence from a subset of scholars and practitioners who seem to strongly support the conventional thinking about community participation and development sustainability. The chapter also exposes two sub-groups of negative opinions that provide evidence that community participation is not always a key factor needed to ensure development success. While discussing both perspectives, the chapter also highlights some of the internal and external factors that have been identified by scholars and practitioners to be equally important to project sustainability across substantive sectors and geographic regions.

Affirmative Views: Community Participation is a Determining Factor to Sustainability Of these 45 studies, 30 authors argued in their evaluations that community participation should indeed be considered a strong determining variable to project success. Most of these 30 studies asserted that the existence or cultivation of community participation alone was already a good predictor of project sustainability. These 30 studies were: G. Honadle (1981), D. Korten and R. Klauss (1984), G. Honadle and J. Van Sant (1985), J. Mayfield (1985), E. Morss et al. (1985), S. Buzzard (1986), N. Uphoff (1986), S. Buzzard (1987), K. Finsterbusch et al. (1987), J. Kean et al. (1987), J. Lieberson et 36

Does community participation really matter to development? 37

al. (1987a), J. Lieberson et al. (1987b), J. Mason and D. Zitek (1987), S. Paul (1987), J. Van Sant (1987), L. White (1987), L. White et al. (1987), R. Chambers (1988), D. Gow (1988), A. Jones (1988), USAID (1988), P. Claquin (1989), T. Hongvivatana et al. (1989), M. Mburu (1989), SIDKenya Chapter (1989), I. Askew and A. Khan (1990), N. Mock et al. (1990), F. Moens (1990), E. Ostrom et al. (1990), and J. Rice (1990). This group of studies (30 of 45) argued that they found a significantly strong relationship between community participation and project sustainability in the development projects they evaluated. Most of them downplayed the importance of other internal and external factors and put much emphasis on community participation. For instance, these studies credit the integration of community participation into a project as the factor that facilitates the mobilization of material and human resources. In addition, according to most of these studies, community participation in the development process itself led to initially donor start-up commitment which was followed by institutional arrangements that sustained the benefits and activities of the projects. Hence, community participation was viewed both as an means and an end. Figure 2 describes diagramatically this group’s perceived relationship between community participation and project sustainability. This group of authors will be referred to as the “optimists” hereafter.

Figure 2. Community participation and project sustainability: Affirmative view

38 Development sustainability through community participation

Pre-Brundtland View (1981-85) All of the pre-Brundtland experts based their evaluations on a combination of sectors. Most of the research approaches used were qualitative in nature. For example, Honadle (1981) developed his arguments from field studies in Indonesia, Jamaica, and Liberia, while Korten and Klauss (1984) combined both field research and case studies from a multitude of countries. G. Honadle emphasized a multiple strategy approach to enhance organizational capability and to empower target beneficiaries. According to Honadle, some examples of strategies which project proponents could synthesize and adopt could come from the pedagogical tools by P. Friere (1969 and 1973) and I. Illich (1974) to organization development (OD) tactics by J. Sherwood (1972) and T. Armor (1981). All of these approaches prescribed a high degree of stakeholder interaction as key to development intervention. This is why Honadle argued that the degree of community participation in the development management strategy was the most critical determinant of sustainability. Honadle implied valuable lessons for donor agencies especially since he argued against the idea of simple resource transfers (e.g. block grants) as key to sustainability. According to Honadle, this common international donor approach does not build local capacity. In effect, this traditional practice resulted in dependency on external assistance as opposed to sustainability. Honadle argued in his article with a strong statement on how he perceived development administration can achieve sustainability: Capacity building is the guts of development. If we cannot figure out how to do it, then the legitimacy of applied social science is undercut. Moreover, an inability to build capacity suggests that “development,” as opposed to the transfer of assets, is an ideology without a technology (Honadle, 1981, p. 1).

D. C. Korten and R. Klauss’ (1984) study argued that sustainability was one of the integral concerns of people-centered development (p. 299). Based on the other studies in the book, Korten and Klauss enumerated the following determinants of sustainability in their conclusion: (1) a public policy addressing the individual, family, and community levels of the political system; (2) organizational structures and processes that function according to the principles of self-organizing systems; and (3) territorially organized production consumption systems based on principles of local ownership and control (p. 302-309). Korten and Klauss argued for the use of the learning

Does community participation really matter to development? 39

process and people-centered approaches as opposed to the blueprint and production-centered approaches to achieve sustainable development due to the formers’ high degree of beneficiary participation in the rural development project (p. 300). In his evaluation, J. Mayfield (1985) balanced the practical experience he gained in the Philippines and other parts of the world (e.g. Indonesia, Egypt, Pakistan, and Libya) with the academic literature on development administration. From his melding of the theory and practice of village development, Mayfield was able to infer the following determinants of sustainable development at the village level: (1) mobilization of local leadership, (2) technology transfer and problem solving, and (3) organization building and effective management. Based on his, J. C. Yen (1934), and other development experts’ experiences, Mayfield argued that participation was imperative to sustaining project benefits (pp. 162-168). E. Morss, D. D. Gow, and C. W. Nordlinger’s (1985) study concentrated heavily on implementation development. Morss, Gow and Nordlinger’s study was the concluding article to this implementation-oriented project. Morss et al. argued that the reasons why project benefits were not sustained was due to the inability of project proponents to interface the following determinants of sustainability: (1) financial factors, (2) economic factors, and (3) institutional factors. Based on their site evaluation studies of numerous projects in different countries (e.g. Kenya, the Philippines, Jamaica, Indonesia, Zaire, Nigeria, and Nepal) Morss et al. argued that participation was necessary to insure the interface of these factors through appropriate beneficiary concern for the long-term sustainability of the project (p. 230). The determinants identified by the development experts of the preBrundtland period (1981-1985) can be categorized into the following: (1) institution-building, (2) importance of local funding, (3) role of management, (4) use of technology, and (5) community participation. These determinants are all characteristics internal to the project. What stands out among these internal project sustainability characteristics is the strong emphasis placed on the determining role of participation in the project. All of these studies by preBrundtland development experts agree that the selection of the appropriate type of participation in the overall development process is the key to sustainability. They mention a number of reasons, ranging from participation’s role as a catalyst of material and human resources to its function as harmonizer of community and donor commitment (Honadle, 1981; Korten and Klauss, 1984; Honadle and Van Sant, 1985; Mayfield, 1985; Morss etal., 1985).

40 Development sustainability through community participation

Post-Brundtland View (1986-90) Partly in response to the call of world leaders in the 1985 Brundtland conference on sustainability in development, there emerged more studies by development experts that dealt with project sustainability in the postBrundtland period than the pre-Brundtland period (40 or 88.88 per cent as opposed to five studies or 11.1 per cent). Similar to the pre-Brundtland development experts, this first group of 25 post-Brundtland development experts argued that their studies reveal a consistently significant relationship between participation and achieving sustainability in development projects. However, they go beyond their pre-Brundtland precursors by arguing for a more enhanced conceptual interpretation of the relationship between the two variables. The post-Brundtland optimists argued that not only is there a significant relationship between participation and sustainability but that the relationship is a strongly positive one. Moreover, they find that projects which treat participation as both a means and an end achieve a higher degree of sustainability. Twenty-three studies subscribing to the optimists’ view used qualitatively-oriented research approaches such as: document reviews (Buzzard, 1986; Mason and Zitek, 1987; Claquin, 1989), field evaluations (Van Sant, 1987; Chambers, 1988; Jones, 1988; USAID, 1988), case studies (Uphoff, 1986; Lieberson et al. 1987a; Lieberson et al. 1987b; White et a i, 1987; Gow, 1988; Hongvivatana et a i, 1989; Mburu, 1989; Askew and Khan, 1990; Mock et a i, 1990; Moens, 1990; Ostrom et a i, 1990) or a combination of these qualitatively-oriented approaches (Buzzard, 1987; Paul, 1987; White, 1987; SID-Kenya Chapter, 1989; Rice, 1990) to support the argument for a strongly significant relationship between participation and sustainability. Additional support for a strong relationship between participation and sustainability during the post-Brundtland period was supplied by two studies that reinforced the optimists’ argument for the existence of a strong relationship between participation and sustainability. These studies utilized a predominantly quantitative research approach (Finsterbusch and Van Wicklin, 1987; Kean et a i, 1987). Both quantitative studies concluded, after extensive operationalizing and statistical analyzing procedures, that there is a strong relationship between participation and sustainability. Some of the variables they attempted to operationalize were: local input, project organization, donor organization, technology, training and management. The number of countries the post-Brundtland optimists evaluated ranged from a single-country study (e.g. Hongvivatana et a i,

Does community participation really matter to development? 41

1989’s investigation of Thailand) to multiple country studies (e.g. USAID, 1988’s evaluation of 212 projects). S. Buzzard’s (1986) study evaluated the lessons learned from USAID health care projects from all over the world. Buzzard enumerated the factors that she thought had significant impact on the sustainability of projects: (1) financing, (2) host country policy, (3) community participation, (4) project design (categorical vs. integrated), (5) resources, (6) implementation, and (7) feedback and communications. Buzzard found a strong relationship between participation and project sustainability (p. 62). Although, Buzzard added that this also depended on the type of health care project. According to her, some projects needed a high degree of participation to be sustained whereas other projects only needed a low degree of participation (p. 37). Buzzard added that beneficiaries were more apt to contribute to projects which they perceived to meet their immediate needs (p. iv). According to N. Uphoff (1986), the importance of local institutions for sustainability of development administration projects had until recently been afforded inadequate attention by government and donor agencies. In this study, Uphoff drew experiences from a host of worldwide case studies. Uphoff explored critical concepts and issues in his examination of various sectors of local institutional development. Some of these sectors include agriculture, infrastructure, and primary health care. Uphoff argued that there were two determinants of sustainable development: (1) local institution building and (2) local control of program. Both of these translated to strong stakeholder involvement (pp. 192-196). S. Paul (1987) argued that the single most important determinant of sustainable development was participation (p. 3). In this World Bank Discussion Paper, Paul studied World Bank application of community participation in the urban housing, health, and irrigation sectors of different countries. Paul sampled 40 development administration projects with potential for community participation (or beneficiary-proponent collaboration) and 10 successful projects without community participation. Paul created the following operational guidelines in his definition of participation: (1) the context of participation in the development project; (2) the focus of participation (i.e. the inputs of beneficiaries, and not that of government personnel or of the donor staff); (3) the degree of participation in groups and sub-groups activities; and (4) the process of participation towards sharing project benefits. After a thorough evaluation of the sample population, Paul concluded that community participation was strongly correlated to the sustainability of a development project.

42 Development sustainability through community participation K. Finsterbusch and W. A. Van Wicklin’s (1987) study was based on a sample of 52 USAID projects. Their samples came from a variety of sectors, including health and agriculture. Using statistical methodology, Finsterbusch and Van Wicklin tested the relationship of the following variables to project effectiveness and eventually sustainability: (1) project organization, (2) contextual factors (including beneficiary participation), (3) donor organization, and (4) local input. Finsterbusch and Van Wicklin’s quantitative analysis indicated that the presence of participation increased the degree of project sustainability (p. 21). Based on five cases studies on development administration projects from Thailand, India, Nepal, Mali, and Honduras, R. Chambers (1988) derived five components of sustainability: (1) using the learning process instead of the blueprint approach; (2) putting people’s priorities first; (3) securing the rights and gains for the poor; (4) starting with self-help; and (5) assembling a good staff with continuity in the field. Chambers believed that the ideal development management approach utilizes the learning process approach rather than the blueprint approach. Chambers arrived at this conclusion based on the evaluations he conducted on successful and unsuccessful projects. In addition, his literature review confirmed that the learning process approach was found to be the most effective change strategy by development scholars (see Korten, 1980, 1981, 1984, 1986; and Rondinelli, 1983). Compared with their pre-Brundtland precursors who concentrated on arguing from an almost totally community participation perspective, the postBrundtland optimists pay attention to some project characteristics (internal) and add a new dimension to their conceptual argument by including contextual factors (external) as determinants of sustainability. The postBrundtland optimists expanded their perspective of participation since they believed that they needed to interpret sustainability with more specific indicators. Aside from the five internal categories mentioned by the preBrundtland optimists, the post-Brundtland optimists’ contribution include the following contextual characteristics (or external factors): (1) host country policy (Buzzard, 1986 and 1987; Kean et a i, 1987; White et al., 1987; USAID, 1988), (2) donor organization and commitment (Finsterbusch and Van Wicklin, 1987, Lieberson et a i, 1987; Lieberson et a i, 1987; Claquin, 1989), (3) coordination, linkages, and support (Mason and Zitek, 1987; White, 1987; Gow, 1988; Jones, 1988; Mock et a i, 1990), and (4) host country economic and political stability (Hongvivatana et a i, 1989). The inclusion, however, of project characteristics and contextual factors did not

Does community participation really matter to development? 43

change the focus of the optimists’ argument. They continued to argue for a strong relationship between participation and sustainability.

Negative Views: Skeptics and Pessimists However, despite this overwhelming endorsement from the development community around the world, a number of skeptical views were also found in the same database sample. Fifteen of the 45 development project evaluations were not as optimistic as the first group. These studies asserted that community participation as the sole preventive and curative medicine to achieve development sustainability is a myth. Table 1 shows the conceptualization of the determinants of project sustainability in these studies. Table 1. Internal and external determinants of project sustainability Project Characteristics (Internal) Project negotiation Institutional aspects Managerial aspects Financing Content aspects Community participation Project effectiveness Leadership

Contextual Factors (External) Natural disasters Political factors Socio-cultural factors Economic factors Private sector and NGO participation Implementing institutions Donor coordination National commitment

Source: Bossert (1990).

Skeptics: Not Necessarily a Determining Factor to Sustainability Five of 45 studies in the database sample argued that they found no clear direct relationship between community participation and project sustainability. This second group pointed out in their evaluations that they found inconsistent evidence showing that community participation actually contributed to the sustainability of development projects. Further more, they claimed that, in their evaluations, they found that certain projects needed community participation to achieve project sustainability while others did not. For example, U.S. AID-supported Central American and African health care

44 Development sustainability through community participation

projects which had community participation as a built in feature were no more likely to be sustained than those which did not have community participation (T. Bossert, 1990). This view and the evidence presented was also shared by the following studies: T. Bossert et al. (1987), T. Bossert et al. (1988), E. Boostrom (1990), and D. Dunlop etal. (1990). The evaluation study of T. Bossert et al. (1987) was the first in a series o f comparative historical evaluations of the sustainability of United States-supported health projects. Bossert et al. examined all completed health projects in Honduras funded by the USAID or its predecessors since the 1940s. The findings were based on document reviews, statistical analyses, site visits, and interviews with Honduran and United States government personnel. Bossert et al. found that when USAID funding stopped, some outputs could be sustained with national funds, but replicating outputs were usually sustained with funds from other donors. An analysis of three cases of high sustainability (nurse training, rural water supply, latrines and pumps) and three of low sustainability (family planning, malaria, and nutrition projects) indicated that: (1) a high national commitment to project goals was necessary but not a sufficient condition of sustainability; (2) projects that were perceived as effective during their life were more likely to be sustained, as were those characterized by cooperative USAID/Honduran planning and implementation (projects viewed as USAID-imposed were not well sustained); (3) vertically organized projects often generated institutional resentment which jeopardized sustainability, while integrated projects tended to be sustained but at lower levels of effectiveness (a matrix-like organization which combines vertical and horizontal components was suggested); and (4) sustainability can be jeopardized if several donors supported the same project and terminated funding simultaneously. It must be noted that projects that received other donor support after USAID funding ended were also likely to be sustained (p.26). Taking off from the early quantitative framework devised by Blumenfeld (1985), Bossert et al. (1987 and 1990) spearheaded several studies arguing that participation may or may not be related to sustainable development. The studies of Bossert et al. were comprehensive in terms of enumerating the variables involved in determining sustainable development. Other significant findings of Bossert et al. in their statistical analysis showed no clear relationship between sustainability and the size of USAID’s funding relative to Honduran contributions to the project, national assumption of recurrent salary costs, cost recovery, or the proportion of the national health budget devoted to hospitals (versus primary health care). Similarly, their analysis revealed that the amount, type, and duration of technical assistance,

Does community participation really matter to development? 45

training, and participation were not significantly related to sustainability (p. 35). The study of E. Boostrom (1990) was based on his evaluation of the sustainability of U.S.-supported health, population, and nutrition programs in Guatemala. Boostrom’s time frame included projects that started from 1942 up until 1987. Boostrom used a similar categorization of factors as S. Blumenfeld (1985) and Thomas Bossert (1990). The factors affecting sustainability were divided into the contextual factors and project characteristics. Boostrom argued that he found no direct relationship between participation and project sustainability (p. 24). He said that participation in Guatemala was a highly sensitive and politicized activity. The national government seldom relinquished the determination of project planning, implementation, and sustainability to individuals in the community. This was the government’s way of controlling the project and show central government priorities. In addition, Boostrom et al. found direct relationships between other factors and project sustainability, e.g. training, technical assistance, and conformity to national priorities. David W. Dunlop et al. (1990) evaluated the sustainability of six health-related projects in Tanzania. These projects included a series of urban water projects, matemal/child health (MCH) aide training, a pilot primary health care program in Hanang District, cancer control, school health programs, and continuing education for health workers. According to Dunlop and his team the activities that were sustained included all the urban water projects, the health components of the MCH aides training project, the curative aspects of the cancer control project, and the village health services component of the Hanang project. However, even most of these projects were having difficulties in continuing to provide services. The water projects all continued to provide services, although maintenance was weak and future demand could not be met with present capacity. The MCH aides who were trained were still providing services although there was some deterioration of services. The hospital-based cancer control center was fully operational and gaining an international reputation. The village health worker program was still active in many villages although there had been a significant dropout of trained workers. The continuation of project activities was negatively affected by a significant decline in Tanzania’s economy, which has severely limited the government’s ability to continue project funding and import necessary medical and transportation supplies and equipment. On the other hand, sustainability had been supported by the political environment, which was characterized by a broad-based and strong ideological commitment to the

46 Development sustainability through community participation poor, as well as a very high level of donor coordination. The success o f the sustained projects underscored the importance of the following design and implementation characteristics to sustainability: (1) the integration of project activities into existing administrative structures and the avoidance of vertical project design; (2) a high to increasing level of project funding through national sources (e.g. budgetary and cost recovery mechanisms); and (3) the provision of visible services and demonstrated effectiveness of project activities to develop demand among provider and beneficiary groups. The Dunlop et al. study confirmed the argument that while in some projects participation was more critical than other factors, in most of the projects, however, community involvement did not seem to have a strong positive relationship to the sustainability of the development activity (pp. 25-26). These development experts enumerate a set of variables that seem more comprehensive than the ones enumerated by the optimists due to the degree of operationalization used. Nevertheless, the internal and external determinants of sustainability they identified can still be grouped into the same categories derived from the optimists: (1) contextual factors (external variables)—natural disasters, political factors, sociocultural factors, economic factors, private sector, implementing institution, donor coordination, and national commitment; and (2) project characteristics (internal variables)—project negotiation, institutional and managerial aspects, financing, content aspects, community participation, and project effectiveness. Moreover, the studies that used statistical analysis developed a detailed operationalization of these determinants to insure measurability (Bossert, Godiksen et al. 1987 and 1988; Bossert 1990). These quantitative studies arrive at the conclusion that participation plays a less critical role in project sustainability. In activities pertaining to cost-recovery mechanisms, financing, and national absorption, the skeptics argue that they found other factors (e.g. financial resources) are more directly important to the overall sustainability of development projects than participation. The skeptics enumerate and emphasize the non-community participation components of a sustainability system surrounding the development project. Examples of the non-community participation components of the sustainability system are the natural environment, cost recovery mechanisms, project design and appropriate technology. In their application of statistical analysis, the skeptics find these external factors and internal characteristics responsible for spuriousness in the relationship between participation and sustainability. Hence, projects with low participation can still be highly sustained because of the indirect role of

Does community participation really matter to development? 47

participation and the direct effect of external factors (e.g. national commitment or continued central government funding). Pessimists: Other More Important Factors to Sustainability Ten of 45 argued that they found no clear relationship between community participation and sustainability. These studies emphasized the importance of other variables as even more important to project sustainability. For example, a common theme shared by these studies was that management was an important aspect of project sustainability but they take no stand about the part of community participation in management as a process. Another more critically determining variable they identified was financing. These internal and external variables were positively identified to be a key determinant to project sustainability and not necessarily community participation. The third group of studies included: C. Stevens (1987), T. Bossert and W. Stinson (1988), A. Goldsmith (1988), G. Rosenthal (1988), A. Abdi-Farah (1989), L. Gilson et al. (1989), P. Hume and P. Savosnich (1989), M. Otero (1989), G. Walt et al. (1989), and R. Levine et al. (1990). Table 2 is a listing o f the studies and their determinants of project sustainability. Carl Stevens’ (1987) review of health care project sustainability concentrated on organizational process, rather than financial issues. Stevens began by outlining a typology that distinguished five types of project components for sustainability analysis: (1) changing health-related behaviors; (2) implementing a health delivery system; (3) training health providers; (4) training health care administrators; and (5) developing planning/management information systems. Stevens added that the USAID should devise a framework in which a “sustainability test” could be applied to projects to determine direction and level of efforts, and allocation of funds. He said that four questions need to be addressed in developing this “test”: (1) what is the “expected yield” of the project; (2) what is an acceptable “probability score” for sustainability; (3) for how long must a project be “sustained”; and (4) is the in-country implementing organization financially viable? In his evaluation, Stevens recommended that the USAID insist that problems affecting a project’s sustainability should not be buried in the “assumption” section of the project’s logframe, but be addressed in realistic and measurable terms. These issues should continue to be dealt with throughout the project’s implementation. Stevens’ study was a quantitatively-oriented review that emphasized the importance of management but did not say anything about participation and sustainability.

48 Development sustainability through community participation

Table 2. Pessimists and their determinants

Determinants o f Sustainability

Study Stevens, 1987

Bossert & Stinson, 1988

Goldsmith, 1988

Rosenthal, 1988 Adbi-Farah, 1989

Gilson et a l, 1989 Hume & Savosnich, 1989

Otero, 1989

Walt et a i, 1989 Levine et al., 1990

• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

changing behaviors delivery system training providers training administrators planning & management information technical effectiveness national leadership & commitment strong management financial resources institutionalized behavioral change external environment local resource endowments management design & approach project activities project outcomes political commitment adequate planning careful logistics media preparation adequate supervision planning flexible approaches management system infrastructure management information system high volume of lending activity appropriate institutional capacity adequate repayment rate management support/supervision systematic integration public-private collaboration cost recovery social financing resource allocation & management service costing

Does community participation really matter to development? 49

The study of L. Gilson et al. (1989) was based on a collaborative research study of policy and practice in the national community health worker (CHW) projects of Botswana, Colombia, and Sri Lanka. Aside from planning and implementation, Gilson et al. said sustainability was raised as one of the critical issues faced by development practitioners. This, according to Gilson et al., could be addressed by utilizing flexible approaches within these three countries’ CHW programs. Gilson et al. do not mention the role o f participation in these approaches. The work of M. Otero (1989) concentrated on the micro-enterprises sector of Honduras in a World Bank evaluation. Moreover, the study was a synthesis of Otero’s experience in conducting micro-enterprises assistance projects in 12 South American countries. Otero found the following three factors critical to the sustainability of a micro­ enterprises project: (1) high volume of lending activity, (2) appropriate institutional capacity, and (3) adequate repayment rate. Otero found that an approach prioritizing the project beneficiaries is critical to sustainable development. In addition, Otero argued that the management system was important to project sustainability but failed to mention the role of participation. G. Walt et al. (1989) evaluated a community health worker project in Botswana. Walt et al. emphasized the importance of sustainability as an issue in each of the projects they evaluated. They concluded that sustainability and the other issues related to it, like problems of poor planning, unrealistic expectations, maintaining quality health care, could be addressed by the integration of the community health workers into the government’s local services system. Despite mentioning internal and external factors to sustainability, Walt et al. make no reference to the importance of participation to the sustainability of the project. The study of R. Levine et al. (1990) was the result of a five-year project by the Health Services Division, Office of Health, Bureau of Science and Technology of the USAID. The project’s goal was to influence policy change, assist in policy implementation and demonstrate and evaluate the effects of alternative policies and mechanisms for financing health services (p. 1). Levine et al. were assigned to review the following technical areas which contribute to the sustainability of development projects in health care: (1) public-private collaboration, (2) cost recovery, (3) social financing, (4) resource allocation, (5) use and management, and (6) health care costing. Levine et al. emphasized the importance of management and other variables to project sustainability but make no mention of the role of participation in the management technique.

50 Development sustainability through community participation

Just like the skeptics, who expressed a critical view of the relationship between participation and sustainability, the pessimists de-emphasized the community participation aspect of the project by concentrating heavily on the material and managerial systems that surrounded the project. The pessimists’ find that these factors were consistently the determining factor in sustaining the development project.

Findings across Sectors and Regions An extended CD-ROM and Online database search of six general area databases and twelve sector-specific databases covering the time period from 1982-1992 was also performed by the researcher at the World Bank in Washington, DC to determine if the arguments of both groups of views— affirmative (or positive) and negative—holds across substantive sectors and geographic regions. Groups of internal and external factors considered by the evaluations to be important to project success were identified. The six specialized development databases consulted were: (1) Sociofile, (2) Social Science Citation Index (SSCI), (3) Humanities Index, (4) Dissertation Abstracts, (5) Economics Literature Index, and (6) the USAID Database. To supplement the interdisciplinary project/program experiences identified from these specialized development databases, a search and identification procedure was also performed into the following twelve sectoral databases: (1) Population, Health and Nutrition-HealthPlan, Medline, Popline; (2) Agriculture and Irrigation-Agricola, CAB, FAO; (3) Education-ERIC, UNESCO; (4) Environment-Environline, Toxline, Pollution Abstracts; and (5) Water supply and Sanitation-TRIS, Water Resources Abstracts. The study dataset was limited to a representative sample of project/program experiences from Asia, Africa and Latin America to the following sectors due to the massive amount of data identified. The sectors were subdivided into: (1) agriculture, including irrigation, forestry and rural development; (2) population/health/nutrition (PHN), including disease control, primary health care, rehabilitation and mental health; (3) water and sanitation, (4) education, including adult literacy, nonformal and formal, primary and secondary, and distance learning; and (5) environment, including recycling, conservation, preservation and waste recovery and management. The project experiences evaluated in this study illustrates that community participation alone cannot ensure project effectiveness. Approximately 85 percent of the over 200 project experiences in this

Does community participation really matter to development? 51

expanded dataset clearly revealed that numerous other internal and external factors in combination with community participation were related to project success. What follows is a grouping, or clustering, of the various internal and external project/program factors identified from the project experiences in the dataset into ten main headings (six internal and four external). Internal project/program factors were grouped into the following six clusters: (1) institutional and organizational arrangements were set-up to encourage and legitimize community member input; (2) local credit and resource mobilization mechanisms were developed to provide needed finacing, (3) training exercises were organized by outside development facilitators to help local community groups acquire the skills needed to participate effectively in program design, implementation, and evaluation; (4) leadership and management systems were established to ensure both community and staff inputs into the decision-making process of the projects; (5) an education and promotion program was implemented by the outside development facilitators which introduced knowledge, information, and technology needed to implement the project; and (6) outside development facilitator(s) or extension agent(s) were involved on a continuous basis to help train, encourage and facilitate local participation. The external project/program factors identified were grouped further into the following four main headings: (1) political factors, e.g. political unrest, ethnic violence, and authoritarian control systems over the project; (2) sociocultural factors which pertains to the situation when the local culture and social system tended to encourage community participation, self-reliance, and societal cooperation; (3) economic factors which refers to low levels of unemployment, extreme poverty and high opportunities for local resource mobilization; and (4) donor (govemment/NGO) commitment and coordination. These four external factors vary in terms of degrees: high to low level of unrest, violence, and national bureaucratic control; high to low degree of traditions and local customs that encourage participation, self reliance, and cooperation; high to low levels of unemployment, high to low levels of poverty, and abundance or inadequacy of local resources. Sectoral Experiences Agriculture. The sectoral breakdown showed that the success of a significant number of agriculture projects were strongly determined by contextual or external factors (i.e. political, economic, and sociocultural) in partnership with community participation. In the agriculture sector, these factors combined with heavy beneficiary involvement facilitated in the following

52 Development sustainability through community participation

projects and programs: Zambia’s North West Province Rural Development Project (mostly community participation and economic factors); Nigeria’s Abiriba Rural Development Project (mostly community participation complemented by decentralization policies); Tanzania’s Dodoma and Singida Region Development Project (mainly community participation and economic, political, and sociocultural factors); the Philippines’ Luzon Agroforestation Project (mostly community participation and economic, political, and sociocultural factors); and Indonesia’s Kali Konto Project (mainly political factors and community participation). Population, health and nutrition. The following variables were identified as significant to development effectiveness for the following PHN projects: (1) extension/monitoring of education, information and appropriate technology; (2) decentralized forms of institutions and organizations; and (3) emphasis on local resource mobilization and direct links with external sources of funding). One example that clearly illustrated this inseparable relationship was the Jamkhed Comprehensive Rural Health Project in Maharashtra, India. This project continues to provide a combination of developmental and social activities intended to raise the living standards of the village community, as well as a comprehensive primary health care package. Many factors contributed to the effectiveness of this project but what stood out were the blending of the following factors: (1) the use of community participation to encourage the involvement of the village beneficiaries especially among the most disadvantaged groups; (2) the establishment and development of appropriate institutions for health information, education, and promotion; and (3) the external health information and technology complimented by community commitment of time, manpower, and materials (see Wolfson, 1987). A number of health project experiences in the dataset shows that primary health care activities initiated by the community pertaining to extended programs on immunization and oral rehydration therapy (technology), family planning and nutrition classes (education), and joint community-health unit assessments (information) improves the overall mortality and morbidity statistics of the target rural population. Other cases of primary health care projects applying the same combination and achieving project success were: Indonesia’s East Java Village Community Health Development project (VCHD), Tanzania’s Maasai Health Services Project, and Bolivia’s USAID-funded El Alto Programma de Desarrollo (PROA).

Does community participation really matter to development? 53

Water and sanitation. The UN’s International Drinking Water Supply and Sanitation Decade Declaration, the USAID’s Water and Sanitation for Health Projects (WASH), the WHO’s Health for All by the Year 2000 Program, among others, motivated governmental agencies, nongovernmental organizations, and private sector groups in developed and developing countries to initiate projects and programs towards water and sanitation activities. During the 1980s and 1990s, financing and other forms of assistance poured into water and sanitation projects in Asia, Africa, Latin America, and the Caribbean. The concentration on water and sanitation programs in the 1980s and 1990s was a shift in priority from the traditional agriculture and infrastructure emphases of development agencies during the 1970s. Similar to the project experiences in the PHN, environment, and education sectors, a main factor, aside from community participation that was identified as important to increased project effectiveness, is related to the information, technology, and education cluster. For instance, the Pakistan Orangi Pilot Project showed that a low-cost sanitation project for a squatter community can improve as long as the target beneficiaries are willing to take on the responsibility of disseminating the necessary information about proper sanitation practices and contribute counterpart labor for the modification of their outdated sewage system. Another related case was Myanmar’s Ayadaw People’s Health Project which won the World Health Assembly’s 1986 Sasakawa Health Prize. The Ayadaw project showed how community participation and the use of appropriate interventions and technology facilitates success. In the dataset, numerous other examples parallel in pattern the Pakistan and Myanmar cases, e.g. Burkina Faso, Togo, Indonesia, and the Solomon Islands’ USAID-supported WASH projects. Other PHN, water supply, and sanitation projects that attribute their project effectiveness to the blending of community participation and appropriate information/technology, institutional and organizational arrangements and local resource mobilization, included: Nigeria’s Bendel State Rural Health System (Ehigiator, 1989); Pakistan’s Orangi Pilot Sanitation Project (Hasan, 1988); and Haiti’s Community Water Systems Development Project (Roark and Smucker, 1987). In addition, the project experiences database reveals that disease vector control projects are most effective when community participation is implemented in combination with health promotion, education, and information activities. Education. In the 1980s, several governmental, nongovernmental, and international agencies increased their project/program activities in the education sector to complement the activities being done in the other social

54 Development sustainability through community participation

sectors, e.g. health, water and sanitation. Compared to other internal and external factors, community participation and information/technology factors play a more critical role in guaranteeing project effectiveness as demonstrated by a number of government-initiated Basic, Vocational, Primary, and Adult Education Projects in Uruguay and Tanzania, NGO-guided Nonformal Primary Education projects such as BRAC’s in Bangladesh, UNESCOinitiated programs in Chile and Uruguay, and the Asian Development Bank (ADB) and UNESCAP-fimded Distance Learning project and Literary and Civic Education for Rural Women project in Asia. The following projects and programs also illustrated the important role played by external factors and community participation in determining project success or effectiveness in education project experiences: Papua New Guinea Buka Educational Development Project (community participation and economic, political, and sociocultural factors); Nigeria Anambra Community Education Program (community participation and politics-decentralization policy); and Latin America and Africa Adult Education Program (mostly economic, political, sociocultural factors, and community participation). Environment. As explained earlier, sustainable development is a concern that started receiving serious attention from international donors in the mid-1980s, e.g. the Brundtland Conference. In response to this new development concern, environmental endeavors such as nature conservation, forest preservation, and waste recovery have all become heavy with combinations of community participation and information/technology factors in project planning, implementation, and maintenance activities. Examples of these projects include: Mexico’s Michoacan Sea Turtle Conservation Project, Laos’ Forest Watershed Management Program, and Zambia’s USAID-funded ADMADE Project. Some environment projects and programs from the dataset were also significant because their success or effectiveness were achieved through the appropriate blending of community participation and contextual factors, e.g. Sri Lanka Biomass Energy Programme (economic factors and community participation), Pakistan Baluchistan Resource Management Self-Help Project (sociocultural and economic factors and community participation), Zimbabwe Communal Areas Management Programme for Indigenous Resources (community participation and economic, political, and sociocultural factors), Bolivia Chorogo AGRUCO Project (community participation and local cultural factors), and Peru Environmental Education Program (sociocultural factors and community participation).

Does community participation really matter to development? 55 Regional Experiences

Asia. Categorized further according to their region of origin, the same three factors (i.e. appropriate information and technology, institutional and organizational arrangements, and financing) were again the ones that come out being needed the most to combine with community participation in order to achieve effectiveness in development project experiences located in the Asia region. Close to 44 per cent of the project experiences located in Asia demonstrate the need for some form of education and information campaign factor together with community participation to increase the likelihood of achieving project effectiveness. Also, 25 per cent of the Asian project experiences cites the need for institutional and organizational factors, while 24 per cent required some form of resource mobilization system (e.g. financing) to go with any community participation efforts for the project to become successful. With the exception of agriculture, the Asian experiences in the health sector, water and sanitation sector, and education sector required information and technology factors over all the other possible variables utilized in combination with community participation to make projects successful. The findings of both the ICMR/WHO Workshop to Review Research Results held in India (1986) and the Fifth Arbovirus Research Symposium conducted in Australia (1989) pointed to the important role played by health care field agents from Sri Lanka, Fiji, China, Papua New Guinea and Southeast Asia in harnessing community participation and delivering technology/information that made disease control interventions in these countries effective. Community participation and nutrition education/information activities are also seen as the key to project success in the implementation of the UNsupported Korea Applied Nutrition Project (Park, 1980). Other Asian cases in the dataset from the water and sanitation and education sectors with similar needs are: Sri Lanka’s Ministry of Health Water Supply and Sanitation program and Nepal’s Primary Education program. In a large number of Asian agricultural projects (including irrigation and rural development), (1) institution and organization development factors and (2) leadership and managerial factors, were cited as the critical partners for community participation to ensure project success. The following are examples of these Asian agricultural projects: Digana Irrigation Project in Sri Lanka, Himachal Pradesh Irrigation Project in Northwestern India, Virtuous and Prosperous Land (VPL) Programme in Thailand, Southern Thailand Rural Development Project, International Institute for Rural Reconstruction (IIRR) integrated rural barangay projects in Cavite, Philippines, and

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International Rice Research Institute’s Cavite, Laguna, and Negros Occidental agricultural development pilot projects in the Philippines. Aside from internal factors, this finding illustrates the need for considering community participation and external project (e.g. economic, political, sociocultural, and donor commitment) to ensure success in a number of Asian agriculture-related projects. This was illustrated in Sri Lanka’s Kukuwela Rural Development Program when the economy of Kukuwela village in Anaradhapura District of Sri Lanka underwent dramatic transformation between 1953 to 1983. Community participation played an important role in the process of adjustment from a traditional subsistence economy to a commercial market economy. Additionally, some Asian health, education, and to a certain extent environmental projects, noted the importance of contextual factors such as political/bureaucratic and economic as critical factors to look at in combination with community participation to insure projects effectiveness. In health for example, China, India, and Thailand’s National Malaria Eradication Programs, Bangladesh’s Ministry of Health-funded Rural Family Planning and Oral Rehydration Therapy Programme, and India’s UNICEFassisted Child Survival Strategies and Population Control Programmes all illustrate the vital role played by community participation and political and economic policies as factors to project effectiveness. Africa. In the African region, community participation and sociocultural variables were stressed alongside information, technology, and financial factors as essential to attaining project effectiveness. Around 33 per cent of African development project experiences discuss the need for the appropriate technology and information-education campaigns in combination with community participation as determinants of project effectiveness. Approximately 26 per cent of the African project experiences cited financing and local resource mobilization schemes, while 20 per cent stressed that capacity to blend in local beliefs, customs, and other sociocultural practices together with community participation were greatly responsible for facilitating the project’s success. As in the Asian and Latin American experiences, a greater number of African projects in the dataset emphasized the need to combine community participation with education, technology, and information factors in order to insure project effectiveness in the health sector, education sector, environment sector, and water and sanitation sector. In the African health sector, the following project experiences show manifestations of this effective combination to ensure project success: Cote d’Ivoire and Kenya’s Tsetse and

Does community participation really matter to development? 57

Trypanosomiasis Vector Control Program detail the use of community participation in setting baits and biconical trap technology; Mali’s Community Health Care Program develops the case for community participation combined with health information dissemination services; Central African Republic’s Glossina Fuscipes Control Project demonstrates the utilization of community participation in setting traps, collecting dead flies, and maintaining the traps; and Nigeria’s National Onchocerciasis Control Programme emphasizes the consistency of community participation and the application of Onchocerciasis control measures. The following projects were examples from the African water and sanitation, education, and environmental sectors that manifested the same effective combination to insure project success: Southern Ethiopia’s Rural Water Supply Project, Egypt’s Public Education Program, and Niger’s Natural Resources Management and Food Aid Program. However, in contrast to Latin America, African educational projects (50 per cent) have the edge over environmental projects (25 per cent) regarding greater emphasis over this internal factor as a determinant of success. As in Asia, African projects emphasized financial factors in combination with community participation as determinants of project effectiveness most especially in the agriculture, health, and water and sanitation sectors. A large number of African agricultural, health, water and sanitation, and education projects demonstrate the demand from project implementors and evaluators to take into consideration community participation in the context of local customs, beliefs, values and other African sociocultural practices to improve the likelihood of project success, e.g. Nigeria’s Imo Rural Development Administration Project, Ghana’s Primary Health Care Program, and the Congo’s Endemic Disease Control Project. Community participation and indigenous village development practices, religious beliefs, and family values are used to provide more grassroots management effectiveness to these endeavors. In the Congo Endemic Disease Control Project, an investigation of the present day sociocultural environment of the Congo was first conducted with a focus on the revitalization of traditional Bantu mysticism and religious worship, particularly practitioners of Kundu, and the ritualization of the trapping of Tsetse flies. During the colonial period, Kundu was prohibited, and the influence of Christianity and modem medicine gradually decreased the power of sorcerers and healers. In the 1960s, however, the eruption of Marxism as an anti-religious theory modified the balance of power once more. Effects on the religious practices and beliefs of the general population were great. However, the Congo Endemic Disease Control project shows that

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Kundu and Christianity have practices that can be used in combination to better address the disease situation and its dysfunctions. The results of this Congo project show that Tsetse fly trapping is enhanced by the integration of beliefs in the supernatural and Western preventive medicine in order to achieve project success. In the Congo, where animism, Christianity and Marxism are closely intermingled, a community participation approach blending these local sociocultural traits is needed to facilitate the control of tropical diseases among the rural population (Leygues and Gouteux, 1989). Latin America and the Caribbean. Political factors were highlighted as project components aside from community participation which contributed heavily towards achieving project effectiveness in the Latin American region. Also identified to be significant were institutional, organizational, information, and technology factors. Moreover, 25 per cent of the project experiences in the Latin American region discuss education, information, and technology as a group of factors in combination with community participation as critical to determining project success. Furthermore, 19 per cent of the Latin American project experiences demonstrate the role of institution/organization factors, while 16 per cent points to political factors as key combinations with community participation in order to attain project effectiveness. Like in the Asia and Africa project experience, community participation in combination with information and technology factors were shown to be most prevalent in Latin American health, education, water and sanitation, and environmental projects. However, unlike the African case this pattern is more prevalent in environmental (80 per cent) as opposed to education (25 per cent) project experiences. A number of Latin American health, water and sanitation, and education projects illustrate the need to combine community participation with institutional and organizational factors to ensure project success. Examples of these project experiences were: San Pedro Health Project in Guatemala, Rio de Janeiro Municipal Services Program in Brazil, Aedes Aegypti and Dengue Control Program in the Dominican Republic, St. Catherine Community-based Rehabilitation Project in Jamaica, Choco Primary Health Care Project in Colombia, IPTBH Water and Sanitation Program in Belize, USAID-funded WASH project in Haiti, and Adult Education Projects in rural Jamaica and urban Bolivia. Health and health-related projects dominated all sectors in terms of demonstrating the need for Latin American experiences to consider community participation in parallel with political factors as a major determinant of project effectiveness. Primary health care projects in

Does community participation really matter to development? 59

Guatemala, Nicaragua, Cuba, Colombia, Mexico, and Costa Rica, all illustrated the need to consider community participation seriously especially in the context of local factionalism, genuine decentralization o f health policies, and influence and representation in decision-making centers. These four community participation and politically-related implications were derived from the project experience of health clinic construction in San Pedro, Guatemala: (1) do not impose an alternate form of representation if competent leadership is already established; (2) consider the amenability of local political forces to a community-wide committee; (3) do not attempt to interfere with decisions once a committee is established; and (4) develop the planning scheme with the existing local organization in mind (Paul and Demarest, 1984). From an analysis of the sectoral and regional dataset, three main factors stood out as the most commonly cited variables that needed to combine with community participation to achieve project effectiveness: (1) extension/monitoring of education, information, and appropriate technology; (2) decentralized forms of institutions and organizations; and (3) emphasis on local resource mobilization and direct links with external sources of funding. This finding provides more reinforcing evidence to the argument that certain internal and external variables are as critical as community participation in achieving project success. It provides more proof running counter to the predominant line of thinking that seems to treat community participation as a “super factor” and other factors as mere supporting variables.

Summary of Findings Does community participation really matter to a development project’s sustainability? Based on the arguments raised by a large group of scholars and practitioners documented in this chapter, the answer is definitely a positive one. However, it is also interesting to note that an equally significant number of their fellow scholars and practitioners do not seem to be fully convinced. These are skeptics who do not quite agree with this seemingly sweeping generalization. The massive development literature reviewed in this chapter also demonstrates support for the position of the more skeptical group since contrary to the numerous assertions by the former, the mere active involvement of the target community cannot ensure 100 per cent effectiveness. The numerous cases and examples in the study show that community participation has certain limitations on the “cures” and “miracles” it can perform unless other factors are taken seriously too. Moreover, even

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though the project experience dataset seems to show a trend in suggesting that certain factors like financing can be more significant in determining project sustainability, policy decision-makers and field implementors should also be cognizant of the fact that there are certain combinations of variables that will increase the likelihood of success. The chapters that follow put these competing views to further “testing” by examining specific cases from the Philippine health sector.

3

Community Participation, Development Sustainability, and the Decentralization of Health Care Delivery in the Philippines

This chapter discusses the influence of the evolving development administration emphases—centralization and decentralization—to health care service delivery in the Philippines. Millions of dollars in technical, financial, and managerial aid from international entities (e.g. the United States Agency for International Development, International Bank for Reconstruction and Development, World Health Organization, United Nations Development Programme, Canadian International Development Agency) have been poured into the Philippines to promote these development-inducing administrative arrangements. The concern for decentralization led to a significant increase of projects and programs all over the country. In the second section of this Chapter, the discussion focuses on the experiences of 38 local-level development projects and programs that resulted after the shift to a more decentralized health care delivery system. It evaluates these project and programs to determine the significance of community participation to their success.

From Centralization to Decentralization in the Health Sector Historically, a centrally planned economic system was in place in the Philippines as early as the 1600s. Through the traditional hacienda system, the Spaniards established massive plantations that produced coffee, sugar, and spices for consumption in Europe. Spain utilized this economic system to exploit the abundant resources of the Philippines until the late 1800s (Gonzalez, 1996). After losing the Spanish-American War, Spain was forced to cede the Philippines to the United States under the Treaty of Paris in 1898. 61

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The Americans continued the concept of a centrally planned economic system, this time focusing on their own interests. The Americans saw the Philippines as a source of raw materials and a market for American finished products. In addition, the Philippines was established as a jump off point for penetrating the growing Asian markets in China, Japan, India and the Middle East. The United States lost the Philippines to Japan during the Second World War. On 4 July 1946, in accordance with the provisions of the Tydings-McDuffie Law, the Philippines was granted its independence by the United States of America. Filipino administrators found themselves faced with responsibilities far greater than they had envisioned. The Second World War had left the Philippines with severe economic and physical destruction. In 1950, the Philippines asked the United States to send a survey mission “to recommend measures that will enable the Philippines to become and to remain self-supporting” (Endriga, 1985, p. 145). In response to this request, the United States government sent a team of elite consultants headed by Daniel Bell. The Bell mission described a very dismal picture of the economic and political realities of the Philippines. The Bell mission made numerous recommendations in response to this post-War situation report. Following the logic of the current thought on administrative reform, they recommended to revive and enhance the centralized administrative system, w'hich was established before the granting of independence. The Bell mission noted that the Philippines inherited from their American colonizers a “reasonably well-organized administration and a well-trained civil service”, but the war and the disarray that followed made it difficult to restore the administrative efficiency it used to have (Bell, 1950). Politically, the Philippines responded to the Bell mission recommendations by establishing the Government Survey and Reorganization Committee (GSRC) under Philippine Republic Act No. 997. The GSRC was tasked with the recentralization of the administrative bureaucracy based on the specifications it had before the Japanese occupation of the Philippines. The GSRC conducted evaluations and made organizational adjustments to government agencies pertaining to agriculture and natural resources, commerce and industry, economic planning, education and culture, health, labor, public works and communications, the revenue system, and statistics and allied research. This marriage between centralization and planned development was clearly manifested in the high priority given to the reorganization of the National Economic Council,1 the central planning body of the Philippine government (see Gonzalez and Deapera, 1987). In addition, the GSRC subdivided the country into eight geographic regions: Region I (Dagupan

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City); Region II (Tuguegarao, Cagayan); Region III (Manila); Region IV (Naga City); Region V (Iloilo City); Region VI (Cebu City); Region VII (Zamboanga City); and Region VIII (Davao City). The guiding principles of the National Economic Council were used as the main blueprint for development planning in the various regional development bodies that were created. These regional development entities were the Mindanao Development Authority and the Central Luzon Cagayan Valley Authority (both organized in 1961); the Hundred Islands Conservation and Development Authority (1963); the Panay Development Authority; the San Juanico Straits Tourist Development Authority; the Mountain Provinces Development Authority (all in 1964); the Mindoro Development Board, the Bicol Development Company, and the Catanduanes Development Authority (1965); and the Laguna Lake Development Authority (1966) (Brillantes, 1987). Each was highly centralized and structured to reflect the logic of modem public administration theory. The recommendations for the establishment of a reorganized central administrative structure affected all government departments including the Department of Health. Based on this planned development model prescribed by the Bell mission and adapted into law by the Philippine legislature, the Department of Health established a system of hospital-based health care administered and accountable to the head office in Manila. A major part of this centralization plan was the creation of Presidential Sanitary Divisions which sought to extend the administrative grasp of policy makers to a number of presidentially-selected rural areas. Manila-trained public health professionals were quick to reject local health systems in the rural areas as primitive and ineffective—labeling traditional village level healers as “quacks” who often did more harm than good through their “herbal concoctions and cures”. The Department of Health presented alternatives to the traditional health system by dispatching medical professionals who prescribed Western manufactured drugs. Unfortunately, as the population grew, the demand for health services also expanded. The Department of Health then found themselves unable to keep up with the demand for more medical professionals and Western medicine because people with even minor ailments travelled great distances demanding to see a doctor in the government hospital. On top of bedside duties, public health professionals in this centralized health care system were tasked with administrative responsibilities like planning, budgeting and personnel management (Carino, 1981). In the late 1950s, Presidential Sanitary Divisions were slowly replaced and renamed Rural Health Units (RHU). These RHUs were

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established in every municipality. The Department of Health introduced the health team approach in each Rural Health Unit. Distinct but complimentary roles were assigned to a Rural Health Unit team composed of a public health doctor, a public health nurse, and paraprofessionals (e.g. midwives and sanitary health inspectors). This new system authorized public health nurses and paraprofessionals “(1) to deal with simple cases that require immediate attention, and (2) to educate the community into more healthful habits and practices” (Carino, 1981, p. 193). The public health physician was tasked with only the most demanding and difficult cases aside from his administrative duties. Further consolidation of the Department of Health’s control over the administration of rural health care services was implemented in the reorganization of 1958. Instead of creating more autonomous units, this 1958 reorganization increased the centralized power of the health bureaucracy by adding more national level staff, administrative, regulatory, and advisory bodies. The full implementation of the reorganization plan was completed in the 1960s. Instead of decentralizing its administrative responsibilities towards the field, the reorganization of 1958 further consolidated the supervisory and administrative powers of the Department of Health through bureaucracyrelated structural changes, i.e. creation of new units and removal of offices with duplicating functions.2 With the exception of the creation of regional offices, all these organizational reforms only reinforced the central planning function of the Manila-based health bureaucracy. These offices also created additional bureaucratic conditions for field operations to pass through. Some of the reforms were changes only in agency name but did not affect the service delivery and operations effectiveness of the office, e.g. the Bureau of Research and Laboratories was renamed the Public Health Research Laboratories—same dog, new collar. Even the creation of regional offices was not enough to bring health care service planning and implementation closer to the people in the village communities. The main beneficiaries of these reforms were politicians and bureaucrats who were able to use the newly created positions in the Manila office as political rewards. Additional organizational changes between 1958 and 1969 again reinforced the centralization of planning and administration in the Department of Health. As in previous reforms during this centralized development period, these organizational changes streamlined the planning operations of the bureaucracy but showed only symbolic concern for field operations. They remained oriented towards the prescriptions of public administration for the use of an effective centralized Weberian-oriented bureaucracy.

Decentralization o f health care delivery 65 This period of planning-oriented development characterized by a centralized and top-to-bottom planning and management process had little effect on people at the village community level. Based on central planning principles, practitioners and scholars of development administration during the 1960s assumed that the careful anticipation of the village community’s problems and the meticulous application of the central government’s prescriptions would lead to success. If implementation failed it was blamed on the beneficiaries’ negligence in following procedures that were carefully described in the initial project blueprint (Gross, 1967; Padilla, 1975). The people at the national level assumed that they knew what was best for the people at all levels of the political system, from the nation-state to the village community level (see Wickwar, 1962; Gomez, 1969; Lee and Samonte, 1970; Groves, 1973; Myers, 1977). Practitioners of planned development adopted the following simple procedures to project design: (1) identification of mistakes in former blueprints; (2) preparation of contingencies ahead of time; (3) laying out a plan that incorporates the contingencies; and (4) accomplishing the goal (Misra, 1983, p.75). Unfortunately, centrally planned development did not lead to the expected capital accumulation and rapid economic growth in most less developed countries, including the Philippines. One general reason was the prevalence of the self-interest of those administering the economic development plans through the centralized system. Another reason was that different interpretations of these national plans led to conflicts on how to implement development efforts. In the Philippines, the most glaring fact was that instead of alleviating the problem of resource inequity, the gap between a small rich minority and a larger poor majority widened. Quality health care remained within the reach of only the privileged segment of the population who lived in metropolitan Manila. In addition, the implementation of the central government’s development plans at the local level met heavy resistance especially from the very people they were supposed to assist. The carefully laid out program and project plans met failure especially when it came to village-level implementation. As demonstrated by development strategies in general and the Philippine health care experience in particular, the predominantly centralized management approach used during this period did not allow for participation by the lower units in development planning. This in effect limited the implementability of development activities. Within the Department of Health, implementation of health care services at the village community-level was hampered by the concentration of manpower in the central office in Manila and other urban centers. This

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existed notwithstanding the fact that 80 per cent of the population lived in the rural areas. The creation of regional offices in 1958 did not provide for delegation of functions and authority. A heavy concentration of administrative duties and responsibilities was still structured in the Manila Central Office, e.g. appointments, leaves, promotions, teaching permits, and overtime services. The health problems of the 1970s were not much different from the 1950s. Despite the centralization of planning for effective development administration, the Philippines continued to deteriorate politically and economically. Graft and corruption permeated Philippine politics. Moreover, the creation of additional personnel positions in the central administrative system was used by politicians as a place for political rewards (spoils system). The centralized economic development plan, which geared the economy towards the exportation of raw materials, was not enough to deal with the balance of trade deficits created by the heavy importation of consumer goods and finished products. The leading causes of mortality during the 1950s and 1960s were pneumonia, tuberculosis, heart disease, gastroenteritis and colitis, diseases of the vascular system, avitaminosis and other nutritional deficiencies, accidents, malignant neoplasm, bronchitis and asthma, tetanus, and diseases of early infancy. The leading causes of morbidity during the 1950s and 1960s were influenza, gastroenteritis and colitis, tuberculosis, pneumonia, malaria, measles, whooping cough, dysentery, malignant neoplasm, tetanus, mental disorder, accidents, bronchitis, heart disease, vitaminosis and other nutritional deficiencies, and diseases of the vascular system. According to health experts, these diseases and illnesses are easily preventable with proper immunizations and sanitation (United Nations, 1964, 1965, and 1977; World Health Organization, 1977). On 9 September 1968, President Ferdinand E. Marcos signed into law Republic Act No. 5435. This Act provided for the creation of a Presidential Commission on Reorganization (PCR), a joint executive and legislative body. The PCR was tasked to develop an Integrated Reorganization Plan. The final Integrated Reorganization Plan for the executive bureaucracy was to be approved by the President. Unlike previous attempts at administrative reorganization, which only further centralized decision-making and resource control, the Integrated Reorganization Plan (IRP) sought to decentralize the Philippine political system. The Integrated Reorganization Plan received critical reviews from members of Congress and government administrators despite representation from the academe, private, and government sectors. Bureaucrats objected

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because the merging and abolition of overlapping and redundant positions would displace many of them. Legislators were afraid that the allocation for political appointments which they used as political rewards would be reduced. Upon the declaration of Martial Law on 21 September 1972, President Marcos abolished the Philippine national legislature. With the abolition of Congress, President Marcos issued Presidential Decree No. 1 which was the first major administrative reform measure under martial law. Presidential Decree No. 1 mandated a review of the Integrated Reorganization Plan for implementation during the martial law period. The 1972 Reorganization Plans impact was felt mostly at the regional level. Under this reorganization plan, regional health offices were established in the newly created regional subdivisions of the country. Each region had a designated regional center in the 12 major cities of the Philippines. According to Alex Brillantes, University of the Philippines Professor, “the Inter-Agency Committee that made the subdivision proposals tried to define relative homogeneous areas, capable of stimulating and sustaining efforts, not only on the basis of administrative consideration, but also with respect to geographic, economic, and cultural factors” (Brillantes, 1987, p. 141). The reorganization plan also authorized the regional directors, in line with the policy of decentralization and within the jurisdiction of the regional office to take final action on matters pertaining to substantive and administrative functions of the agency. In an effort to decentralize their administrative and resource control over village community level units, the Department of Health in the late 1970s and early 1980s introduced the following programs: (1) Restructured Rural Health Care Delivery System (RRHCDS), (2) Medical Care Program, (3) Rural Health Practice Program, (4) Community Medicine Focus of Medical and Nursing Schools, and (5) Community-Based Health Program (Carino, 1981; Azurin, 1988). Restructured Rural Health Care Delivery System (RRHCDS) The RRHCDS was implemented in 1975 as part of some recommendations embodied in the World Bank’s Population Program. The most significant contribution of the RRHCDS Program was the creation of Barangay Health Stations (BHS). Barangay Health Stations are the first line of health care available at the village community level. They are staffed by a government trained midwife and other barangay health workers. Through the financial support of the RRHCDS, the health structures housing the BHS were also constructed.

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Medical Care Program (MEDICARE) According to the primer of the Philippine Medical Care Commission, the MEDICARE program was envisioned “to provide the people with a practical means of helping themselves pay for adequate medical care” (1974, p. 1). This program has assisted in the construction of hospitals in the far flung areas of the country. Although its main beneficiaries are limited to the employed and their families, the MEDICARE Program has created access to hospital-based health care facilities for the rural areas (Carino, 1981). Rural Health Practice Program In order to respond to the growing need for health care in the rural areas, the Philippine government required rural health service as a mandatory requirement for all medical and nursing graduates before receiving their professional licenses. The volume of manpower that augmented the rural areas helped ease the burden on health care professionals working for the Philippine Department of Health. It also instilled a much-needed sense of community service to the country’s future doctors. However, Carino notes that “questions have been raised in other studies as to its effectiveness, efficiency, and effects on the morale of regular personnel and efficacy as a training tool for underboard nurses and medical doctors” (Carino, 1981, p. 194; see also Reforma, 1978). Community Medicine Focus o f Medical and Nursing Schools Pioneered by the Rural Health Program of the University of the East-Ramon Magsaysay Memorial School of Medicine in 1964, Philippine medical and nursing schools created programs that stressed preventive and social medicine and rural medical practice. These medical and nursing schools emphasized heavy implementation of the pre-graduation requirement of rural health practice. They also made curriculum changes that aimed at placing more attention on Philippine medical problems. In addition, a Bachelor of Science Degree in Rural Medicine was introduced at the University of the PhilippinesTacloban City. A rural practice internship at the nearby Carigara area was the highlight of this program. The national Rural Health Program patterned after a number of pilot projects combined features of community-based health care programs and the community medicine approach utilized by the regular medical schools.

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Community-Based Health Program (CBHP) In the early 1970s, the CBHP approach was endorsed by both nongovernmental and governmental organizations as their contribution to bringing health care closer to the rural areas. This approach promoted the use of multi-function village health workers who administer first aid, teach health education, provide sanitation attention, and serve as the first person to turn to for minor illnesses. They see health as only a part o f an overall village development package. Hence, these village health workers also facilitate community organizing and impart income generation skills to the members of the village community. University of the Philippines Professor Victoria Bautista (1989) in her study enumerated several individuals who promoted pilot projects targeting specific rural areas using the CBHP approach, e.g. De La Paz with the Katiwala Program in Davao City, Viterbo of Roxas City, Macagba of La Union, Flavier of the Philippine Rural Reconstruction Movement, Campos of the University of the Philippines Comprehensive Community Health Program, Solon of the Paknaan Cebu Institute of Medicine Project, and Wale of Silliman University (Bautista, 1989). In addition, J. Galvez-Tan (1986) noted that attempts at replicating this program nationally was promoted by the Rural Missionaries of the Philippines. Other religious groups like the National Council of Churches in 1977 and AKAP in 1978 followed suit with their own nationwide applications of the CBHP approach. These groups applied almost similar types of participation approach towards the institutionalization of an appropriate health service delivery system.

M ore Changes to the System Structural reforms in Philippine health care continued until the 1980s but they no longer took the centerpiece of decentralization reforms. The highlight of the 1980s shifted to the call for the adoption of primary health care all over the world. Primary Health Care was essentially a call for sustainable health development through behavioral changes, e.g. community participation and active beneficiary and proponent collaboration. This shifted the emphasis of decentralization from a structural focus to a more process orientation. In 1977, the World Health Organization (WHO)-sponsored Alma Ata conference formally mandated the international goal of “Health for All by the Year 2000” (HFA). The goal of “Health for All by the Year 2000” could be traced back to the Constitution of the World Health Organization which was

70 Development sustainability through community participation adopted in 1946. It had taken the WHO more than 30 years to actually formalize a program that dealt with the issue of sustainability. This delayed reaction was similar to the OECD’s late response to sustainability which had been in the OECD Constitution since 1961.3 The international delegates present at the conference agreed that Primary Health Care was the key to achieving this long-term objective. The framers of the HFA Declaration envisioned Primary Health Care to be: an approach that recognizes the inter-relationship between health and over-all socio-economic development. It aims to provide essential health services that are community-based, accessible and sustainable at a cost which the community and the government can afford through community participation and active involvement. Ultimately, it aims to develop a self-reliant people, capable of achieving an acceptable level of health and well-being (Italics provided) (Azurin, 1988, p. 58). As opposed to previous strategies that concentrated on prescribing structural decentralizations of the bureaucracy and its parts, this statement clearly implied that health care projects under the Primary Health Care program were to be grounded on sustainability through collaboration, interaction, and involvement at the community level. In response to this, the Philippines, together with the international community of nations, redefined their health care approaches towards the achievement of “Health for All by the Year 2000” (see Appendix 1).

Primary Health Care and Community Participation The health problems of the 1960s and the 1970s did not change significantly. The leading causes of morbidity in the 1970s continued to be acute respiratory infections, diarrheal diseases, tuberculosis, malaria, skin infections, and enteritis. The leading causes of mortality in the 1970s also remained the same, i.e. pneumonia, tuberculosis, bronchitis, diarrhea, heart disease, malignant neoplasms, and accidents (Ministry of Health, 1978 and 1979). These health care problems were hampered by the following administrative and resource constraints: (1) insufficient funds; (2) lack of medical and paramedical manpower; (3) inefficient use of scarce health services available; and (4) lack of community support for health programs.

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With this backdrop in mind, President Marcos issued Letter of Instructions 949, mandating the implementation of the Primary Health Care approach throughout the country starting in 1981. Primary Health Care offered a medical outreach approach different from the hospital-based western health care models which proved to be ineffective in less-developed countries like the Philippines. A national coordinating council for primary health care headed by the Department of Health and other concerned departments (e.g. Food and Agriculture, Social Service, Natural Resources) was immediately established. This coordinating council was duplicated in the different administrative regions, provinces, municipalities, and villages of the country. In 1981, President Marcos declared a new Philippine Republic and ordered the implementation of the revised Integrated Reorganization Plans of all departments subject to his approval. In addition, he changed the Philippine administrative system from a presidential to a parliamentary model. Hence, all government departments were renamed ministries. According to then Minister of Health J. Azurin, the adoption of Primary Health Care all over the Philippines moved him to seek the immediate Presidential approval of the revised organizational chart of the Ministry of Health (MOH) contained in Executive Order No. 851 (see Appendix 2). Minister Azurin added that this action would accommodate all of the behavioral changes needed to make the MOH more participationoriented. The most significant change of the 1982 reorganization was at the provincial level with the merging of the Provincial Health Office and the Provincial Hospitals (Azurin, 1988, p.35). In the Philippines, the Primary Health Care approach concentrated on the main health problems in the village community, providing promotive, preventive, curative and rehabilitative activities. Promotive health activities are personal and environmental hygiene, sound food and dietary practices, regular physical exercise, and a low stress lifestyle. Preventive health activities are occupational health, immunization, quarantine, vector control, and disease surveillance. Curative health activities are early diagnosis and treatment of diseases, emergency care of the injured, and other applications of medical technology to repair tissue damage brought about by acute or chronic illness or injury. Rehabilitative health activities are the restoration of normal physical, mental and social functions to individuals afflicted with disabling injuries and illnesses as well as extension of services to minimize the extent of disability caused by impaired or damaged body tissues and organs (Azurin, 1988, pp. 40-41). Because these services reflect and evolve from the economic conditions and social values of the country and its village communities, they vary by country and community, but include at least

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promotion of proper nutrition and an adequate supply of safe water; basic sanitation; maternal and child care, including family planning; immunization against major infectious diseases; prevention and control of locally endemic diseases; education concerning prevailing health problems and the methods of preventing and controlling them; and appropriate treatment for common diseases and injuries. In order to make Primary Health Care universally accessible in Philippine village communities as quickly as possible, maximizing community and individual self-reliance for health development was mandated. Specifically, to attain such self-reliance in Philippine village communities required full community participation in the planning, organization and management of Primary Health Care. Such participation was best mobilized through appropriate education, which enabled village communities to deal with their real health problems in the most suitable ways. Village communities thus were put in a position to make sure that the right kind of support was provided by the other levels of the national health system. These other levels were organized and strengthened so as to support Primary Health Care with technical knowledge, training, guidance and supervision, logistic support, supplies, information, financing, and referral facilities including institutions to which unsolved problems and individual patients could be referred. Philippine program administrators believed that for Primary Health Care to be most effective it needed to employ means that were understood and accepted by the community, and applied by the community health workers at a cost the community and the country could afford. These community health workers, including traditional practitioners where applicable, functioned best if they resided in the community they served and were properly trained socially and technically to respond to its expressed health needs (Ministry of Health, 1985). Since Primary Health Care was an integral part of the country’s health system and of overall economic and social development, it had to be coordinated on a national basis with the other levels of the health system as well as with the other sectors that contribute to the country’s total development strategy (Ministry of Health, 1985). Mutually beneficial linkages as opposed to administrative direction were encouraged by the primary health care approach. Upon her assumption to power in 1986, President Corazon C. Aquino immediately called for another comprehensive reorganization of the Philippine administrative system. One of the first pieces of legislation President Aquino issued was Executive Order No. 5. This law reconstituted and renamed the Presidential Commission on Reorganization as the Presidential Commission

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on Government Reorganization (PCGR). The five guiding principles of the PCGR were as follows: (1) private initiative, (2) decentralization, (3) costeffectiveness, (4) efficiency of frontline-services and (5) accountability. The PCGR was composed of high caliber Filipino consultants from both the private and public sector who were divided into survey teams headed by a coordinator. The PCGR had a policy group and a special studies group. These groups were in charge of standardizing, collating, and compiling all the survey team’s findings. The final approval of the each departmental reorganization plan was left solely in the hands of President Aquino. This was due to the absence of a legislature which was abolished after the Fidel V. Ramos and Juan Ponce Enrile-led coup d ’etat. The absence of the legislature also gave the Chief Executive the power to carry out the reforms without arguments coming from the other political branch of government. The scope of the PCGR’s mandate as defined under Executive Order No. 5 was truly encompassing. It involved the overall and sweeping reorganization, reorientation, and restructuring of the whole Philippine administrative system including line agencies, attached agencies, government owned and controlled corporations, and local governments. Never in the history of Philippine government restructuring had a single entity been accorded this massive task of reorganization. Under President Aquino, the department model of government was again revived. This reorganization furthered the cause of process-oriented decentralization by constitutionally encouraging Primary Health Care through collaboration, interaction, involvement from the national level to the village community level. The changes instituted under the 1987 Reorganization of the Department of Health were: (1) creation of the Community Health Service and Field Epidemiology Training Program; (2) development of a simplified and realistic health information system; (3) computerization of the main Department of Health for greater efficiency of services; (4) creation of a NGO coordinating desk within the Department; (5) rationalization of the Department’s procurement system; (6) development of legislative liaison; and (7) strengthening of the District Health Office, Rural Health Units, and Barangay Health Stations (see Appendix 3). Following the general guidelines of Primary Health Care’s “sustainable health development through participation mandate”, more definite and specific operating principles and approaches towards process decentralization and service déconcentration were introduced by the Philippine Health Department under the Aquino Administration (see Department of Health, 1988, p. 5).

74 Development sustainability through community participation Community Participation in Health Care Projects/Programs The move to devolve health care delivery to the local local level spawned many projects that introduced various degrees of stakeholder involvement in the country’s barangays. However, not all health care projects achieved sustainability due to project characteristics and contextual factors aside from low community participation. Enumerated below are brief descriptions of the health care project experiences from Luzon, Visayas and Mindanao. Located in Southeast Asia, the Philippines is comprised of over 7,100 islands clustered over these three main geographic regions—Luzon in the north, Visayas in the center and Mindanao in the south. To the west and north of the country is the South China Sea, while to the east is the Pacific Ocean. The total land area of the Philippines is approximately 300,000 square kilometers. Luzon Area Luzon has the highest population density among all the three regions. It is where Manila, the capital city, is located. The Luzon area can be divided further into the following regional groupings: Metro Manila (or the National Capital Region), Ilocos Region, Cagayan Valley Region, Central Luzon Region, Southern Tagalog Region, Bicol Region, and the Cordillera Autonomous Region (CAR). More than 50 percent of the projects (21 out of 38) identified and evaluated were from Luzon. Eight projects had high community involvement while 13 had low community participation. Seven projects with high stakeholder collaboration were found to be effective while one was not. Ten projects with low client participation were not sustainable. Three projects were still effective despite not having adequate community support. Binan health maintenance organization (HMO) project. The Binan HMO project was implemented by two Philippine NGOs—Hewspecs, Inc. and the Intercare Research Foundation. The site selected for the project was Barangay San Antonio, Binan, Laguna. The project was initially financed by the Philippine Council for Health Research and Development and the United States Agency for International Development. The goal of the project was to generate financial resources for maintaining community health to Binan residents. According to Department of Health officials, the Binan HMO scheme would be recommended for replication to other communities if it is found successful.

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The proponent involved key community actors (e.g. town mayor, local health officials, and prospective recipients) in the setting-up of the project through numerous informal discussion sessions and formal meetings. According to some members of the Binan HMO, they have had a strong demand for an alternative health financing schemes in the past but have not been able to firm up any ideas. This demand from the community facilitated the collaboration between the Binan residents and Intercare and Hewspecs officials. The start-up project was planned and implemented in 1987-1988. The initial planning and implementation stages were difficult for both the proponents and beneficiaries because they were just starting to blend ideas and suggestions from both sides. There were times when differing interpretations of policies led to disagreements between staff members and service recipients which threatened to jeopardized the HMO project. These disagreements affected membership recruitment during the initial start-up project. The initial conflicts also resulted in slow and inconsistent growth despite the intensive information campaign and recruitment drives. Aside from these institutional and managerial aspects, political and economic factors were also involved. As the project passed its second and third years of operation beyond the initial one-year “honeymoon” period, these policy conflicts diminished and membership increased. Initial fears of nonsustainability due to lack of financing from the community faded as the proponent and beneficiary interactions increased. Frequent meetings and discussions between these two principal groups led to creative ideas on sustaining the project both resource-wise and manpower-wise. So far, the project has been sustained for five years beyond the start-up project. Cabalantian, Matabungkay, Legaspi Population Commission projects. Key proponents of all three family planning projects were the Department of Health (DOH) through their local-level Rural Health Units (RHUs) and a nongovernmental organization. The projects sites were: Barangay Cabalantian in Pampanga, Barangay Matabungkay in Batangas, and Barangay Legaspi in Albay. The three projects utilized a bottom-up approach to participation. Beneficiaries and proponents collaborated in the primary health care activities which provided the community with preventive, promotive and curative care. Local health practitioners, leaders of the community, members of the community were all heavily involved in the planning, implementation, and sustaining of the project. It could be deduced from De La Salle University Professor Stella Go’s 1989 study that high participation characteristics in all three projects could be the primary variable for sustaining the projects for 12 years beyond the initial start-up in 1978.

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Munoz community-based health project (CBHP). The project’s goal was to provide supplemental primary health care services to the village community of Munoz, Nueva Ecija. The Munoz-CBHP was started by the Munoz parish priest after the local rural health unit admitted that it could not provide an adequate health care program due to lack of funds, material, and personnel. The initial start-up project was assisted by the Missionary Medical Actions, a church-based nongovernmental organization (Laleman and Annys, 1989). Though informally linked to the Catholic church hierarchy, the Munoz-CBHP project had the autonomy to carry out activities and services deemed necessary by the community and proponents. Broken down, the term community-based health program describes the project’s approach and organizational character. “Community-based” mandated an active community and proponent coordinating and collaborating system regarding project decisions, activities, and resource management. This was implemented through project-established village institutions, e.g. cooperatives and user associations. “Health programs” implied the type of services and benefits the project provided. The Munoz project offered an integrated range of services which even went beyond health care. The Munoz-CBHP project had active beneficiary and proponent interaction from the beginning of the project in 1978 until 1988 when it was last evaluated by Geert Laleman and Sam Annys (1989). Project compassion. The project’s proponents were an NGO and the local government of Rizal. Project Compassion was initiated to provide much needed integrated health care services and benefits to the village community of Teresa, Rizal (Caraso and Fernando 1982). These services and benefits were a packaged program that included nutrition, family planning, green revolution, environmental management, and sports and cultural development. The organizational structure of Project Compassion harmonizes the involvement of both informal and formal public and private actors into project activities. Lessons from previous passive participation experiences of the community led to this organizational structure. The numerous jointly-planned activities of the Project Compassion were effectively carried out. The proponents’ utilization of a social learning approach in the start-up project was instrumental to the implementation and maintenance of the project’s services and benefits. It was deduced from the Caraso and Fernando (1982) evaluation that Project Compassion lasted from 1976-1990 due to a high degree of proponent and beneficiary interaction in support of the project. The project was sustained for 14 years beyond the initial one-year pilot stage.

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Bagong Silangan primary health care project. The objective of the project was to provide primary health care services to a rural community in the most remote area of an urban area. The project was located in Bagong Silangan, Second District of Quezon City (Maglaya, 1982). The approach used in developing the project was characteristic of a social learning approach. In the planning of the Bagong Silangan project, the proponents were receptive to the suggestions and comments of the project beneficiaries. Discussions and meetings became the venue for gathering ideas and creating the project plan. There was beneficiary and proponent partnership in the implementation of the project. This included various community-inspired activities like the training of community health workers who were familiar with the traditional norms of the area. According to several evaluations the high degree of beneficiary and proponent involvement in all phases of the Bagong Silangan Primary Health Care project could be the main cause of the projects sustainability (Recio, 1982; The Committee on the Bagong Silangan Nursing Clinic Project, 1982; and Corcega, 1982). Liwayway primary health care project. The Liwayway Primary Health Care project was conceived by the Philippine Nursing Association-Nueva Ecija Chapter. The main objective of the project was to provide community-based primary health care services to Barangay Liwayway in Santa Rosa, Nueva Ecija. The approach to planning and implementing the project had the characteristics of a social learning process, wherein a highly interactive situation existed between the proponents and beneficiaries throughout all the activities of the project. Community assemblies and informal meetings became the main venues for suggestions, criticisms, and discussions pertaining to the project. Despite a high degree of participation within the project, a misunderstanding about the extent of coordinative linkages with external institutions, e.g. local government agencies, and resource constraints limited the project sustainability to two years (1982 to 1984) (David, 1984). Isabela malaria control project. The project was initiated by the Department of Health in Cabagan, Isabela to control the spread of malaria to other neighboring barangays. The project was not effective at quelling the spread of malaria despite the intensive application of curative (e.g. fumigation and treatment), preventive (e.g. keeping closed water bins), and promotive (community education) health care services and activities (Lariosa, 1986). The organizational structure of the project was directly linked to the Department of Health’s centralized bureaucracy. The research and evaluation

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methodology of the project was quasi-experimental in orientation, i.e., surveys were used to gather medical information on the community. The topto-bottom structure and quantitative approach of the project did not allow for active beneficiary and proponent interaction. The proponents dominated all phases of the project. Planning activities were handled by health experts from Manila. The project lacked community-inspired inputs into the promotive and communication schemes. Cultural and traditional values were not incorporated into the design of the materials used in project implementation. It can be inferred from the Lariosa study that the low participation characteristics of the project could have been a contributing factor to its not being sustained beyond the initial start-up period. Benguet mobile clinic project. The objective of the mobile clinic was to provide health cares services (i.e. promotive, preventive, curative, and rehabilitative) to remote village communities which were seldom visited by professional health care providers (Lara, 1985). The area of the project was Benguet, Mountain Province. The main proponent of the project was Saint Louis University, Baguio City with financial support from Canada’s International Development Research Center (IDRC). The organization and structure of the project was highly centralized. The main factor maintaining an effective level of services and benefits during the three year start-up project was financial resources from IDRC and the manpower support of Saint Louis University’s School of Nursing. Lacking in the project was active community participation in support of the project’s objectives. Linkages to governmental and nongovernmental groups who might have had an interest in sustaining the project were not explored by the proponents. Because of its ambitious mandate and lack of community support, the Mobile clinic project was not sustained beyond the three year start-up implementation period from 1982-1985. Sampaloc mental health project. The aim of the project was to provide policy information for a community-based mental health care in Sampaloc, Quezon Province. The proponents of the project included the World Health Organization and academic representatives from universities all over the world. The degree of interaction between the proponents and beneficiary was passive. The beneficiaries were mere respondents to the surveys and interviews administered by the project proponents. The project resulted in a policy paper for use by academics and health experts. The real beneficiaries of the project’s findings were the sponsoring international organization and the Department of Health, because significant impact to the community was

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only made during the initial pilot project application. The L.L. Ignacio et al. (1987) evaluation showed that the project’s pilot mental health activities were not sustained beyond the initial start-up project (See also Ignacio et al. 1983). Their follow-up evaluation in 1989 reconfirmed their negative findings about the project. Tarucan USAF clinic project. The project was initiated by a United States medical team from Clark Airforce Base, Pampanga. It was a two-day free medical consultation project in a village community in Tarucan, Tarlac (Beaumont, 1981). The USAF-Clinic was a medical outreach project designed by the United States airforce to contribute to community development in the area where the military facility was located. The approach to the project seemed ethnographic in orientation but was not so in actual application. The project team was made up of a physician, two dentists, a nurse, a pharmacy technician and medical and dental assistants. The project team provided free medical consultation and curative services to the community. They also socialized with the village beneficiaries by eating and exchanging stories with them. The village was appreciative of the services given them by the USAF Clinic team. A true ethnographic approach would have produced more long-term benefits and activities for the community. The pseudo-ethnographic approach used by the USAF Clinic team considered the community members as recipients of the advanced U.S. technology they brought. The problems conveyed to the team members in the socialization activities never received extended attention. According to informal discussions with beneficiaries of the project, the non-sustainability of the project could be attributed to the project’s low participation characteristics. The activities and services provided to the community by the clinic team were not sustained beyond the initial project. Bocaue and Cabanatuan community outreach survey projects. The objective of the projects was to provide family planing consultation services to two village communities. These two communities were Barangay Bocaue in Baliuag, Bulacan and the Poblacion barangay in Cabanatuan, Nueva Ecija (Versoza et al., 1984). The approach to the projects looked highly participatory in nature because it involved discussion groups. The discussion brought about lively interactions from both the proponents and beneficiaries. The resulting interaction, however, was useful only to the project proponents because they were not able to come out with specific action plans for the communities they targeted. The project results became the basis for support

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materials on family planning using the rhythm method now being used throughout the country. The target communities did not receive a significant impact from the project after its conclusion because they were treated as subjects of the project instead of partners for change. The respective rural health units under the Department of Health and not the communities took charge of implementing the project recommendations. The low degrees of community participation used in the Bocaue and Cabanatuan Outreach projects could be a leading factor for the non-sustainability of the projects beyond the initial pilot study periods. Negrito health project. The objective of the project was to provide much needed medical and dental outreach services to a Negrito village community. The proponent of the project was a U.S. Navy medical team from the Subic Bay Naval Base, Olongapo. The location of the project was in Barangay Pastolan in Hermosa, Bataan (Heise, 1982). A project team composed of U.S. Navy medical and dental personnel was assembled to assist a nearby ethnic community as part of the Navy’s community relations program. As in the U.S. Airforce’s Tarucan clinic project, the approach seemed ethnographic in nature but really played lip service to the rigorous nature of ethnography. The interaction between the proponents and beneficiaries was limited to just one day. This timeframe was too short for substantive exchanges to take place. Moreover, the Negritoes were passive participants to the project, being mere recipients of the health care services. More long-term responses to the health care problems of the community were not given adequate attention because the consultation and lecture sessions were dominated by the proponents. The Negrito project’s objectives and approach were similar to the USAF Clinic project in Tarucan, Tarlac. Hence, the results of the project were the same. The project services and activities were not sustained beyond the start-up outreach project. San Juan Filariasis and blood examination project. The location of the project was Barangay San Juan in Bacon, Sorsogon. The project was initiated by the Department of Health through the local Filariasis Control Unit (Ventura, 1986). The methodological orientation of the project was experimental in design. This use of the quantitative approach limited the degree of interaction between the beneficiaries and proponents, because there was a set of rigorous procedures that the academic researcher and government personnel had to follow. The proponents clearly dominated the conduct of the project. The participation of the target beneficiaries were the roles of the experimental group (service acceptors) and control group (non-acceptors). In

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other words, they were the subjects of the project. The impact of the project output was irrelevant to the immediate needs of the community. One output was an evaluation study that became part of the Department of Health’s policy paper for the Bicol Region. Another output was a publication of the project study and findings. This showed that the main beneficiaries of the project were actually the proponents. The project was not sustained beyond the one-year project planning and implementation period. This could be due to the low community participation and other characteristics not anticipated in the project design and execution (Ventura, 1986). Cuenca health worker training project. The goal of the project was to enhance the capacity of the traditional community health workers (iherbolarios) in providing quality primary health care by giving them a oneyear training. The project was initiated by the Department of Health. The location was in Cuenca, Batangas (Caragay, 1982). The health project targeted the training of village healers about integrating more scientific techniques in medicine with their traditional medical procedures. Though the intentions of the government were good, the means by which they approached the project were unsatisfactory. Most of the discussions with the target herbolarios and their health care recipients (96 per cent of the community members) were passive interactions. The project proponent team composed of health experts dominated the discussions and merely “informed” the people about the expectations of the project. Because of their biases, the proponents were not very receptive to the perspective of the herbolarios. Nevertheless, the beneficiaries left the discussions promising to try out the new system. The herbolarios agreed to refer a certain level of illnesses to the rural health units or hospitals instead of trying to “cure” all cases. The herbolarios also agreed to prescribe only over-the-counter medicine. The initial community enthusiasm for the project was not sustained for a long period of time (Caragay, 1982). After the initial training project, only a few herbolarios continued to attend meetings and coordinate with the rural health units. Most of the herbolarios saw the system they agreed to in the training project conflicting with their local practices. Many people also felt that they did not have the time and money to travel to the rural health centers after being referred there by the herbolarios. The people continued to stick to the herbolarios'’ herbal medicine which they found to be effective, inexpensive, and readily accessible. Because of these socio-cultural and project effectiveness factors, the project outcome was sustained for only one year. The main issue of correcting traditional beliefs that “West is best”, “doctors know all”, and “hebolarios are unreliable charlatans” re-emerged

82 Development sustainability through community participation two years after the termination of the initial project. In his evaluation, Caragay argued that a more social learning-oriented approach to the project would have melded the best of both traditional and Western medicine and value systems. Bulacan nutrition project. The project covered 18 small village communities in the Bulacan area. The project was conducted from 1975 to 1979. The objective of the project was to gather nutrition information for policy recommendations (Solon et al., 1984). The proponents of the project were the Department of Health, Nutrition Center of the Philippines, Nutrition Research Institute, and several academic institutions from the Philippines and the United States. The methodological orientation used was quantitative. Control and experimental groups were used to study the differences between four types of nutrition interventions. The proponents used the project beneficiaries as subjects of the study. The degree of interaction between the proponents and beneficiaries was passive. The only input the beneficiaries had on the project was the baseline information they gave, which was subjected to statistical analysis. All activities of the project were dominated by the proponents from the planning to the final evaluation report. Despite the low community participation characteristics of the Bulacan Nutrition project, it was sustained beyond the initial start-up period for two years. The main factors responsible for sustainability were the financial and management commitment o f the Philippine government. Laguna and Batangas USAID-primary health care projects. Both projects were initiated by the USAID and the respective local governments of Laguna and Batangas to assist in moving health policy from curative to preventive health care (Varela, 1984). The Laguna project was started in 1980 while the Batangas project was initiated in 1979. Both projects were linked to the highly centralized structure of the Department of Health. The project was planned in Manila by representatives from both the Department of Health and USAID. Department of Health professionals and their staff manning the rural health units dominated all aspects of implementing the project. Beneficiary input to both the planning and implementation of the projects was minimal. Interaction between the proponents and beneficiaries was passive and selective. Few residents attended the meetings arranged by the proponents because of their mistrust of governmental policy which was developed without their active participation. Those who attended were mainly informed of the services and benefits of the project but were never there to be consulted on the planning and implementation. Being showcase Primary Health Care

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projects, the government of the Philippines sustained the projects after the full consumption of the USAID-assistance through managerial and financial support. The Laguna Primary Health Care project was sustained for 10 years whereas the Batangas Primary Health Care project was sustained for 11 years. Visayas Area Major cities in the Visayas are Cebu and Iloilo. The Visayan region can be divided further into Western Visayas, Central Visayas, and Eastern Visayas. Nine out of the 38 projects (23.6 per cent) identified and analyzed were from the Visayan region. Four projects had high community participation while five had low community participation. The four projects which had solid community support were effectively sustained. Three programs with low community participation were not sustained. Surprisingly, two projects with little stakeholder support were still evaluated to be successful. Hanunuo Mangyan health project. The Hanunuo Mangyan Health Development project was conceived by the De La Salle University (DLSU) research team, an academic non-governmental organization. The project was financially assisted by Canada’s International Development Research Centre. The location of the project was the Hanunuo Mangyan community of Oriental Mindoro. The project duration was from 1985 to 1991. The project’s objective was to assist the Hanunuo Mangyan community in developing its own self-sufficient community health care system. The DLSU project team was guided by a participatory action research (PAR) approach and an integrated objective that looked at health care as only a part of an over-all socioeconomic program (Osteria, 1986). Based on the results of the participatory research and planning phase, services and activities were developed. One of the initial Hanunuo Mangyan project activities was the selection and training of personnel responsible for administering the project to the community (Osteria and Okamura, 1988). The project resulted in the specific health care outputs enumerated earlier, e.g. training; construction of physical facilities; technical, managerial, and financial capacity; and organization of members. Specific health care outcomes included behavior modification towards a concern for personal hygiene and community cleanliness. Specific status changes included a decrease in morbidity and an increase in life expectancy. The proponents interviewed, who constantly monitor and evaluate the project, indicated that the Hanunuo Mangyan Health Project, with predominantly community

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resources, continued to provide these essential health care services, benefits, and activities five years after the withdrawal of the DLSU research team (see Osteria and Okamura, 1988; Osteria and Ramos-Jimenez, 1988; Osteria et al., 1988; Osteria, 1990). Sudtonggan project. The proponent of the Sudtonggan human development project was the Institute of Cultural Affairs, a non-governmental agency. The objective of the Sudtonggan project was to provide an integrated socioeconomic development scheme to assist the village community of Barangay Sudtonggan, Basak, Lapu-Lapu City in Cebu province. The pilot project started with a survey of both rural and urban communities within the vicinity of Cebu. Sudtonggan was selected because of its immediate need for assistance and the willingness of the community to work for the project. Community health care services was a core program in the Sudtonggan project aside from community education (Functional Skills Academy), community formation (Community Improvement Association), community agriculture (Sea Food Project), and community commerce (Sudtonggan Industrial Complex). The proponents used a qualitatively-oriented methodology in facilitating action from the community members. Initial activities such as problem identification, community organization, project promotion and guidelines were jointly planned and implemented by the proponents and beneficiaries. From the start-up project until 1991, the active involvement of both the beneficiaries and proponents in the planning and implementation of programs continued to be the highlight of the Sudtonggan project. The organizational character was a bottom-up one. The highest decision-making body was the Community Assembly, which included all the residents of Sudtonggan. The day-to-day activities of the Sudtonggan project were managed by a Board of Directors (combination of proponents and beneficiaries) and project staff (all Sudtonggan residents). After four years of guidance by the Institute of Cultural Affairs, the management o f the Sudtonggan project was turned over to the community in May 1980. The Institute of Cultural Affairs role in the project was reduced to an advisory one. The Sudtonggan project was sustained for six years beyond the initial start-up project (Ricana, 1981; Albano etal., 1982; Bautista, 1989b). Leyte Makapawa project. The goal of the project was to provide primary health care services to village communities which were underserved by the Department of Health. The location of the project was in Palo, Leyte. The proponent of the Makapawa project was the Rural Missionaries of the

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Philippines, a Roman Catholic service order. The start-up period of the Makapawa project saw several trying stages of development before the project was able to reach a degree of long-term maturity. Makapawa’s general objective called for the building of just communities through commitment from people for total human development. The process used to achieve this general objective were: (1) awareness of the situation in which structures were preventing the attainment of basic human needs for many; (2) organized community action to promote total development; (3) self-reliance of the people to the extent of their personal and local resources; and (4) increased participation of the people in decision-making which affects their total social development (Barrion, 1980). During its first year, Makapawa was heavily dependent on the centralized hierarchy of the Catholic Church. After the second year, the project gained autonomy from the Church but still maintained an advisory link to it. The project also maintained coordinative links with government and non-governmental groups. A low degree of participation characterized the initial phase of the project. Because of lack of managerial experience, the beneficiaries were not prepared to handle the project by themselves. Hence, meetings and discussions were dominated by program staff and health professionals. As the beneficiaries gained experience running the project, they became more confident in actively exchanging views with the proponents’ especially during their regular meetings. Due largely to the high degree of community involvement and the use of a learning process approach to participation in the project, the Makapawa project has been sustained for 15 years beyond the initial three-year start-up project (De Leon, 1982; Rifkin, 1983; Robillard, 1986). Makapawa’s success has inspired the Rural Missionaries to replicate the program to other village communities in the Luzon and Mindanao regions. The findings of these three documents were confirmed by three of other studies (Pagaduan and Ferrer, 1983; Rifkin, 1985). Panay PUSH project. The PUSH (Panay Unified Services for Health) project was initiated by the Department of Health in cooperation with the United States Agency for International Development. The objective of the PUSH project was to provide primary health care services (e.g. family planning, nutrition, and community organization) to selected rural village communities. The location of the project was the island of Panay (Capul et al., 1984). The methodological orientation of the project was ethnographic in approach. Despite being government initiated, the PUSH project was highly successful in developing active collaboration and interaction from both the proponents

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and beneficiaries of the project (Capul et al., 1984). The PUSH project was sustained for six years beyond the initial one year start-up period. Bohol infant and child mortality project. The project was initiated and evaluated by the Department of Health under its Maternal and Child Health/ Family Planning program. The objective of the project was to decrease the incidence of infant and child mortality through the prevention of neonatal tetanus, instructions to mothers on oral rehydration therapy (ORT), giving of DPT and BCG shots, encouragement of breast feeding and enhanced nutritional practices, and making family planning available (Williamson, 1982). The project was carried out through the highly centralized administrative system of the Philippine health bureaucracy. The degree o f interaction throughout the duration of the project was dominated by the local and central government health experts. The methodology used in the project was highly quantitative. The accuracy of analysis based on the survey instruments was doubtful because of incomplete information. The project beneficiaries were not given an active role in the decision-making for the planning and implementation activities of the project. The project services were not sustained beyond the initial four-year (1975-1979) start-up period because of the failure to see any significant improvement in the community’s mortality record even after the long health care service period. Cebu health and nutrition study project. The objective of the project was to provide nutrition services to a village community in the island of Cebu. The project was initiated by a joint local and expatriate study team (The Cebu Study Team, 1991). The organizational structure of the Cebu longitudinal health project was based on top-to-bottom model. The academic team dominated all aspects of the the project from the planning to the evaluation activities. The methodological orientation was quantitative. The proponents used a survey approach to gather the baseline information on the beneficiaries of health and nutrition assistance. Due to the proponent’s chosen approach there was practically no input from the beneficiaries except for their responses to the sampling instruments. The project resulted in a publication paper but did not produce substantive impact on the health care situation in the community. The project’s non-sustainability after the two-year initial planning and implementation phases could be due to the low participation characteristics of the Cebu Health and Nutrition study.

Decentralization o f health care delivery 87 Bacolod community-based rehabilitation project. The project’s objective was to provide community-based rehabilitation services to a rural barangay in Bacolod, Negros Occidental. The proponents of the project included the WHO, UNICEF, the National Commission Concerning Disabled Persons (NCCDP), and the Department of Health. Four major disabilities were targeted by the project: moving, speech and hearing, seeing, and learning. Under the supervision of the Department of Health, the project was introduced into the community with the assistance of a local project committee. The project committee was composed of representatives from both beneficiaries and proponents. On the surface, the project seemed to have a bottom-up organization. In reality, however, the project was influenced by directives and expert support from the proponents (especially the Department of Health). The expectation of active proponent and beneficiary interaction occurred only during the initial start-up period. This degree of interaction slowly changed to passive collaboration as the project progressed. The inputs of the proponents became increasingly more dominant than the beneficiaries. The project was able to strengthen its external linkages with government and some private organizations, but the ability of the project to develop its fiscal capacity with the help of the community was played largely ignored. The project was sustained for two years after the initial implementation project (Periquet, 1989). However, the project failed to continue providing services to the beneficiaries when the secondary and tertiary providers system failed to support the continuing referral needs. Another contributing factor to the non-sustainability of the project were the financial burdens on the community brought about by country-wide natural (flood and earthquake) and man-made (political mismanagement) disasters which drained the national government of resources that had been earmarked for sustaining the project. Cebu nutrition intervention project. The objective of the project was to evaluate and subsequently provide nutrition intervention and family planning services to a village community. The location of the project was in two selected barangays in the Cebu area. The proponent of the project was the Philippine government (G. Guthrie et a i, 1980). The government used a quasi-experimental approach in conducting the evaluation of the community’s nutrition and family planning situation. The government’s nutrition and family planning project was structurally linked to the overall health policy set by the central office of the Department of Health in Manila. Hence, inputs to the actual resulting policy was dominated by the health experts who conducted the project. The methodological orientation of the project was

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quantitative in nature. Surveys and interviews were administered to target beneficiaries. The beneficiaries participated in the project by providing information on nutrition and family planning. After the survey responses were analyzed, the beneficiaries then became the recipients of the resulting policy on enhanced health care services, e.g. milk and dietary supplements. Interaction during meetings and discussion sessions was heavily dominated by government personnel. Despite an approach with low participation characteristics, the project was sustained for six years after the start-up period (Barba et al., 1982; G. Guthrie, 1984 and 1988; H. Guthrie et al., 1990). Mindanao Area Located south of Manila, Mindanao is a resource rich region. Major cities are Zamboanga, Davao, Iligan and Cagayan de Oro. Its total land area is larger than Luzon. The Mindanao region can be divided further into Northern Mindanao, Western Mindanao, Central Mindanao, and Southern Mindanao. The Autonomous Region of Muslim Mindanao (ARMM) is also located in this area. Eight out of the 38 projects (21 percent) identified and evaluated were from the Mindanao region. Five projects had high community participation characteristics while three were low on stakeholder involvement. Five projects were successful while three were not. Four projects with high community involvement were among those sustained while two projects with low beneficiary collaboration were not sustainable beyond the formative years. Despite having adequate community support, one project failed while one which had low beneficiary participation was still sustained. Katiwala project. The Katiwala Project was a project concerned with the delivery of primary health care to a village community in the Davao area. The major proponent of the Katiwala project was the Davao Medical School Foundation. The project was called the Kaunaunahang Katiwala ng Kalusugan (First Guardian in Health) but this was later shortened to Katiwala. Some of the services and activities of the project included providing training to community-based health workers and enhancing community reliance on promotive and preventive health care as opposed to curative care. As time passed, income-generating projects such as backyard gardening and poultry-raising were integrated into the Katiwala activities. The project had its roots in a health intervention scheme by a unit of the Christian Family Movement in Davao City. To discourage dependency of the clients to the program in 1972, the Development of People’s Foundation took over and

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reoriented the program into a health care cooperative. The Davao Medical School Foundation took over the Project in 1976. The Regional Development Council (RDC) of Region XI, the highest policy-making body in the region, adopted Katiwala as its main social development program after giving it a very favorable assessment (Alfiler, 1983; Alfiler, 1986; De La Paz, 1983). There was a high degree of active community and proponent interaction and collaboration in the Katiwala project. The methodological orientation used was a process of action research. At the time of evaluation, the Katiwala project had been sustained for 19 years. The relationships between participation, sustainability, and other variables have been discussed in the evaluation performed by University of the Philippines Professor Ma. Concepcion C. Alfiler (1983 and 1986). This information was cross-checked with information from a follow-up study (Alfiler, 1986) and an outside evaluator (De La Paz, 1983). Bagong Slicing project. The objective of the Bagong Silang project was to initiate a rural development consultation-training project for peasant women. Health care was just one aspect of the project’s integrated approach to development. The proponent of the Bagong Silang project was the Women’s Studies and Resource Center (WSRC), University of the Philippines and the Network for Participatory Development (NPD), both nongovernmental organizations. The project was located in Davao City, Southern Mindanao. The methodology used in the project was high in active beneficiary and proponent involvement. In the planning phase, demographic information about the beneficiaries was collected and analyzed by both the community members and project proponents. The action plan was drawn with inputs from all stakeholder groups. In the implementation phase, the initial demand for a coordinating organization, actual services, and physical infrastructure was fulfilled by the community members themselves. In the sustainability phase, various groups contributed time and resources to the project (e.g. the parish priest allowed the use of the convent for meetings and some farmers donated earnings from their crop sales). Moreover, a coordinative and supportive relationship was developed between all the project stakeholders (both governmental and non-govemmental) concerned with the project’s activities (Pagaduan, 1988). Due to beneficiary and proponent collaboration and interaction and the decentralized organizational structure, the Bagong Silang project continued to provide services and benefits to the community for five years beyond the initial planning and implementation phases.

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Agdao and Punta Dumalag primary health care projects. The Agdao and Punta Dumalag Primary Health Care projects were initiated by Health Care Mindanao, a nongovernmental organization affiliated with the Catholic church. Health Care Mindanao had a similar personnel structure as Makapawa with a physician, public health nurses, and community organizers. The projects were located in Agdao and Punta Dumalag, Davao City. Health Care Mindanao assisted the project beneficiaries with training programs for prospective health workers. The beneficiaries came up with the physical infrastructure to serve as health center for both the professional and paraprofessional health providers. The health centers were staffed by two full-time health workers who receive monthly compensation from the community association. To curtail the communities’ heavy reliance on Western medicine, the project beneficiaries also developed a herbal garden. The project experienced numerous difficult situations. The most persistent obstacle was the high rate of community health worker turnover due to the small amount of compensation. But the project continued to weather these obstacles to sustainability with active community and proponent action (Robillard, 1986). Health Care Mindanao used a decentralized organization in planning and implementing the project. The active involvement and collaboration of the community and proponents in almost all phases of the project were instrumental to the Health Care Mindanao village project’s sustainability for five years beyond the initial start-up project (Robillard, 1986; Osteria and Okamura, 1986). Kapunongan ng mga Ina project. The proponent of the project was the Kapunongan ng Mga Ina-Katilingbon Programa Para sa Maayong Panglawas (Kapunongan ng Mga Ina or KMI), a religious-based non-governmental association. The KMI project was located in Kibawe, Bukidnon (Rifkin, 1977). The initial project was started in 1974 and originally named the Bukidnon Committee for Community Organization (BCCO). The original members of the BCCO were laymen and religious persons who believed in people participation as a means for empowerment. The mandate of the initial project was to act as a support group for the training and organization of rural farmers in the area. The members of the BCCO convinced the farmers that the only way to counter the strength of the owners of the land, which they tilled, was through organized action. From this suggestion emerged KMI as a political, social, and economic action group. KMI was handled by mothers from the core BCCO group. They decided to address the problems of health apart from the political agenda of the BCCO. The KMI was successful in delivering much needed services (nutrition and health worker training) with

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the active involvement and collaboration of community beneficiaries and proponents from outside the community (e.g. Prelature of Bukidnon, UNICEF, Catholic Relief Services, and CBHP of the Rural Missionaries). The Kapunongan ng mga Ina was sustained for three years after its autonomy from BCCO. The high degree of participation that existed in the project was not enough to sustain KMI’s services and activities for a longer period of time. The KMI’s activities and services slowly declined as support from outside proponents diminished. The beneficiaries were not able create local resource support mechanisms (e.g. income-generating activities). They relied too much on the continuing support of agencies like UNICEF and Rural Missionaries which also had their own financial constraints. Mindanao Contraceptive Pattern project. The Contraceptive Pattern project was developed to derive family planning information from a number of remote barangays in Northern Mindanao. This data was analyzed by the study team and processed for use by policy makers for improving the health care delivery to the barangays. The project was initiated by a local study team from Xavier University, Cagayan de Oro and the Virginia Polytechnic Institute and Virginia State University of Blacksburg, Virginia. The members of the community were considered subjects of the research. They had no input into the planning and implementation of the project. The proponents utilized a quantitative approach to the project. Surveys and interviews were administered to a sample population from each of the selected barangays. The information collected from the instruments was aggregated and analyzed statistically. The real beneficiaries of the project were not the community members but policy makers and researchers who read the final report. Because the primary intention of the project was to produce a study for academic publication, the long-term impact on the community was not significant. The community members’ participation in the project was their response to the statistical instruments. The Contraceptive Pattern Project had no benefits to the community that were sustained beyond the project planning and implementation phases (Tan et a l, 1984). Mindanao Schistosomiasis project. The project’s aim was to gather information for the control and prevention of schistosomiasis in a remote Mindanao community. The project was inspired by two previous schistosomiasis studies conducted in Samar (Lewert, 1979) and Oriental Mindoro (Carney, 1981). The project proponents included the Mindanao Schistosomiasis Control Team of the Department of Health, the central office o f the Department of Health, the Institute of Public Health and School of

92 Development sustainability through community participation Economics from the University of the Philippines, and the Research Institute for Mindanao Culture from Xavier University. The planning process was dominated by the Mindanao Schistosomiasis Control Team, who brought in representatives of the community to “inform” them of the project’s objectives. Interest in the project was expressed by the community with representatives giving suggestions on how to make the project more effective. Their suggestions were heard and written down in the planning meeting’s minutes but were overshadowed by the preconceived plan of the schistosomiasis team (Herrin, 1986). The actual conduct of the project was dominated by the use of a preliminary survey research methodology. Due to their perceived familiarity with the Mindanao area, personnel from Xavier University and the local RHU were the ones who administered the surveys to and interviews with community residents. The data from these surveys were analyzed by the economists and health experts from the University of the Philippines. Several Mindanao community members indicated that it was essential to sustain the project for an extended period of time, but they were not prepared to do so because of previous heavy reliance on government resources and the lack of active interaction among community members and with the government team members. Even though the community was planning to organize a health committee to support the project, they were not able to do so after the one-year project because this activity was not listed as a top priority in the organizers preconceived plan. During the one-year duration of the pilot Mindanao schistosomiasis project, the proponents were able to emphasize the need for behavior modification to reduce the risk of disease transmission. According to the researcher’s interpretation of the government report and the Herrin study, the Mindanao schistosomiasis team was not able to prepare the community to sustain the project because of the lack of active involvement and interaction during the planning, implementation, and sustaining processes and reliance on mostly central government resource mobilization. During interviews with officials of the Department of Health and the University of the Philippines, these two groups admitted that active community involvement in the decisions made in the planning and an ethnographic approach during the implementation of the project could have resulted in a more accurate interpretation of the local community’s needs. Nueva Ecija, Iloilo, and Lanao Del Sur primary health care projects.The proponent of these three projects was the Department of Health and the staff members of the individual rural health units (RHUs). The Primary Health

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Care projects were located in Nueva Ecija (Luzon), Iloilo (Visayas), and Lanao Del Sur (Mindanao). The three projects utilized a top-to-bottom type of participation. According to RHU staff members, the beneficiaries “participated in the discussions” by providing baseline information for the use of health experts. The role of the beneficiaries were recipients of policy handed down by bureaucrats from the central offices. The researcher’s observations of the conduct of the meetings, the health professionals (physician or public health nurse) were the ones dominating and benefiting from the discussions. Beneficiaries were present in the meetings only by invitation of the health professionals (Bautista, 1989a). This domination and at times cooptation shows the political aspect of health care projects. The degree of participation did not change across geographic regions (Luzon, Visayas and Mindanao). Despite passive beneficiary and proponent collaboration in the planning and implementation of these projects, the three projects were sustained for five years beyond the start-up period. Typical of government supported projects, the three projects were not sustained by active beneficiary and proponent collaboration but rather by the financial and organizational support of the Department of Health (see also Alfiler, 1986).

Summary of Findings The move from centralization to decentralization in Philippine health care delivery led to the creation of many projects and programs at the local government level. Together with decentralization came many assumptions about how service delivery would become more efficient, effective, and responsive. For instance, it was assumed by policymakers that community involvement would increase as envisioned by the Health for All by the Year 2000 Declaration in the Alma Ata Conference. However, it must also be remembered that the HFA declaration’s framers emphasized to all that sustainability can only be achieved through genuine and active collaboration, interaction, and involvement at the community level which was not the case in all the Philippine projects examined for this study. Hence, the 38 health care projects showed a diversity of results. On one hand, in support of the positive view were 15 projects with high community participation which were sustained while an equal number of projects with low community participation were not sustained. On the other hand, reinforcing the negative view were two projects with high community participation which were considered to be not sustainable while six projects in spite of low community participation were still found to be sustainable. This

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leads us to conclude that many internal and external factors which were identified in the project evaluations were equally critical to the sustainability or failure of a program aside from simply community participation. The succeeding chapter provides a more in-depth examination of four health care projects reinforcing these two contrasting views.

Notes 'Later known as: National Economic Development Authority (NEDA). 2Aside from J.C. Azurin (1988), the researcher examined various inter-office communications pertaining to the Department of Health’s 1958 reorganization. 3It was only after the 1985 Brundtland Conference that the OECD addressed this important development issue. For more information about the implementation of the PHC in the Philippines, see Executive Order No. 851, Letters of Instructions No. 949 and Presidential Decree No. 1397.

4

The Cases of Four Philippine Health Care Projects

The relative mix of Philippine health care sector cases presented in the previous chapter illustrating the significant or non-significant role of community participation to project sustainability merits a closer examination. Hence, this chapter responds to this need by providing a much-needed indepth look at four interesting cases from the 38 health care projects described in the previous chapter. These projects are: (1) Matabungkay Population Project, (2) Hanunuo Mangyan Community Health Project, (3) Mindanao Schistosomiasis Control Project, and (4) Nueva Ecija Primary Health Care Project. These development project experiences are evaluated to determine the degree of community participation, institutional arrangements, project characteristics, and contextual factors that contributed to their sustainability or non-sustainability. The first two projects provided support to the affirmative view that community participation is a strong determinant of project sustainability while the last two projects reinforce the dissenting perspective about community participation’s significance to the development effectiveness.

Positive Cases Matabungkay Popcorn Project1 Philippine population program. The creation of the Philippine Population Program was a response to a call to decentralize the administration of health development projects in the Philippines in order to respond to the urgent need to reach mothers and children in the rural areas. The Philippines has a large population of mothers and children. In 1980, mothers and children composed 66.1 per cent of the total population. A large majority of them lived in the rural village communities of the country. Infants composed 22 per cent of the total deaths in 1980 despite the fact that infants constituted only 3.5 per cent 95

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of the total population in the same year. O f these infant deaths 45.5 per cent occurred during the neonatal period. Moreover, maternal mortality was 54 per cent of the total number of deaths in 1980. Structurally, the National Commission on Population (Popcorn) was created under Executive Order 171 issued by President Marcos in 1969. In 1971, Republic Act No. 6365 justified a national family planning program directed at reducing the high rate of population growth in the country: For the purpose of furthering national development and increasing the share of each Filipino in the fruits of economic progress, and meeting the grave social and economic challenge of a high rate of population growth, a national program which respects the religious beliefs of the individuals involved shall be undertaken.

In 1972, Republic Act 6365 was amended by Presidential Decree No. 79 which redefined the role of Popcorn to include the following: (1) The formulation of population policies integrated with broader socioeconomic development. (2) The recommendation of policies and programs for guiding and regulating labor force participation, internal migration, and spatial distribution consistent with national development. (3) The provision of family planning as a part of overall health care. (4) The making of family planning a part of a broad educational program.

The 1970s saw numerous attempts at developing Popcorn as a decentralized working organization. Starting in 1970, the structural organization of Popcorn included a Board composed of 22 members from both the public and private sectors. In 1972, membership to the Board was reduced to five, i.e. the Secretaries of the Department of Education, Culture and Sports, Department of Health, Department of Social Services and Development, Dean of the Population Institute of the Philippines, and the Director-General of the National Economic and Development Authority. The Secretary of the Department of Social Services and Development was the Board Chair. Between 1972 and 1975, numerous presidential decrees and letters of instructions were used to induce support for Popcorn activities in the newly strengthened national, regional, provincial, and municipal levels of

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government. In 1975, the position of Executive Director was created to overseethe day-to-day operations of Popcorn. In 1977, the Board membership was increased to 10, to include the Secretaries of the Department of Labor and the Department of Local Government and Community Development. Aside from the Popcorn Board, there is a Popcorn Secretariat, Popcorn Regional Offices, Popcorn Provincial Offices, Popcorn District Offices, Popcorn City and Municipal Offices, and Popcorn Barangay Units, all organized to implement a more decentralized approach to family planning. Unfortunately, all of these increases and reductions in board membership implied the use of top-level structural decentralization with little efforts to introduce process-oriented change which could be felt at the grassroots level. The only significant decentralization change at the village community level was the creation of the positions for Full-Time Outreach Workers (FTOWs) and volunteer Barangay Service Point Officers. The outreach workers provided initial training and supervision to the work of the service point officers. The process aspect of the Popcorn’s program’s decentralization effort was emphasized in the 1980s in response to the recommendation of the Special Committee to Review the Philippine Population Program (SCRPPP). As noted in Chapter II of this book, the structural and functional dimensions of the 1970s gave way to broader socio-economic development objectives of the 1980s: Philippine population policy should be formulated within a framework of social and economic reforms which may enable the population to create new standards of demographic behavior (National Economic Development Authority, 1977, p. 19).

This general health development objective revised the 1970 goal of simply fertility reduction to an overall emphasis on the interaction between the individual, family, and society (National Commission on Population, 1980). In the late 1980s, the population program emphasized the need for sustainable health care development through: (1) promotion of self-reliance through community-based approaches and (2) maximum utilization of participative and consultative approaches. Both these goals focused on a decentralized process of interaction and local level participation. Because of the Department of Health’s renewed efforts to decentralize its organizational objectives in the mid-1980s, international organizations like the World Health Organization, the World Bank, and United States Agency for International Development were attracted to support financially some of Popcorn’s grassroots-enhancing efforts towards

98 Development sustainability through community participation sustainable health care in the Philippines. Popcorn’s NGO partner in the project was the Family Planning Organization of the Philippines (FPOP). This organization was the result of a 1969 merger between the Family Planning Association of the Philippines (established in 1965) and the Planned Parenthood Movement in the Philippines (established in 1966). The FPOP developed programs in family planning education, training, and clinic services all over the country (Go, 1989). This consolidation of NGO family planning efforts created an organization which integrated much of the duplications and overlapping of functions between the two previous family planning organizations. Research data pertaining to family planning and population were developed by the Population Institute of the University of the Philippines (1964) and the National Training Center for Maternal and Child Health Services (1967). Both these research institution were funded by the national government. The project site. Barangay Matabungkay is one of 19 barangays in the Municipality of Lian in the province of Batangas. It is about 120 kilometers south of Manila in the southwestern region of the main island of Luzon. As of 1985, Barangay Matabungkay had a population of 2,500 in 350 households. The elementary and secondary educational needs of Barangay Matabungkay are serviced by one elementary school and one high school. Most of the community residents are farmer-tenants engaged in agricultural production. The bulk of their earnings (70-80 per cent) go towards rental and profit sharing with rich landlords and what is left (20-30 per cent) is only enough for daily subsistence. There are four established community groups in the barangay. These community associations are: Samahang Nayon, a government cooperative organization of farmers; the Samahang Pangkabuhayan, a government livelihood project which allows members to obtain loans from larger government livelihood programs; Mother Butler, an association of mothers doing charity work; and TIGAS, an association of married couples which assists the community in its social activities, particularly fund raising (Go, 1989). Though the community is serviced by a Barangay Health Station (BHS), its health services have no emphasis on family planning and very little concern for maternal and child health. Most of the work of the BHS is in preventive medicine, health education, and environmental sanitation. The two most common projects in the area are the Expanded Program on Immunization (EPI) and “Operation Timbang”, which involves monthly

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check-ups, child weight monitoring, provision of a monthly supply of food supplements such as powdered milk, and a mother’s class on basic food requirements of children. A Popcorn reconnaissance team was informed by the Barangay Captain (village community head) of Matabungkay that in a number of previous community meetings residents had indicated to him the need to request family planning services. According to the Barangay Captain, the demand for these types of services increased in the village community as the number of married couples seeking smaller families grew. Moreover, this type of health service was not easily accessible to community residents because the nearest government facility was 40 kilometers away, whereas the nearest private facility was located ever farther. The Barangay Captain added that he had already brought this problem to the attention of local officials during the past two terms that he had been in office and had continuously been informed that the province of Batangas did not have adequate financial resources to provide this wide ranging health services in Barangay Matabungkay. Nevertheless, the Barangay Captain told the Popcorn representatives that the village community was very willing to support a project in whatever way they could, given their limited resource mobilization capacity. This initial interactive exchange with community leaders and members led the Popcorn team to recommend Barangay Matabungkay as a priority area for assistance. With financial support from a large USAID and Philippine Government grant, Popcorn and FPOP decided to help pre­ identified barangays in selected provinces to start-up their own family planning and maternal and child health projects. In 1978, Barangay Matabungkay was one of the village communities in the province of Batangas selected to be a beneficiary of this population program’s aid package. Organizational orientation. In the 1970s, the traditional perception of Philippine governmental health care providers was that Philippine non­ governmental organizations were competitors in rural health care delivery. On the other hand, non-governmental organizations viewed governmental providers as corrupt, inefficient, and ineffective. This view changed in the 1980s when the Department of Health acknowledged the role of nongovernmental organizations as partners in health care delivery. During this period, these two groups of Philippine health care providers decided to extend their partnership to the rural village communities of the country. The organization orientation of the Matabungkay Popcorn project was the result of the commitment between Popcorn, a governmental agency, and FPOP, a non-

100 Development sustainability through community participation governmental organization. Because of the GO-NGO partnership nature of the Matabungkay Popcorn Project its organizational orientation was decentralized compared to the centrally-oriented projects and programs planned and supervised by the Department of Health. Traditional Central Office projects have policies and decisions come down to them from the top of a tall administrative structure centered in the Department of Health main office in San Lazaro, Manila. This tall administrative structure has multiple layers of national, regional, provincial, municipal, and district offices. All of these administrative layers have functions and responsibilities that directly or indirectly affect the management of any Department of Health project at the village community level. Although start-up funds for the Matabungkay Popcorn project came from both international and national level sources, the project was managed at the village community level by field representatives of Popcorn and FPOP in cooperation with the residents of Barangay Matabungkay. Major decisions for the Matabungkay project did not come from the National Population Commission head office nor the Department of Health’s Matabungkay Barangay Health Station. Project decisions and activities were derived from interaction processes developed and agreed upon by both the project team representatives and community beneficiaries. The goals of the Matabungkay Popcorn project were the following: (1) identify and train full-time outreach workers and barangay service point officers from the village community; (2) motivate, recruit and refer acceptors (users of family planning materials and devices) to the new population component of the Barangay Health Station; (3) conduct surveys for prospective family planning acceptors; (4) distribute contraceptive supplies; and (5) coordinate with field workers from other governmental and nongovernmental agencies. Degree o f interaction. Interaction among the groups involved in the project was characterized with active participation. Evidence of this active interaction was the strong willingness shown by proponents and beneficiaries to implement the project with resource mobilization contributions from all parties. The succeeding sections further explain this interaction. Community residents through their elected local officials convened a barangay assembly open to all and determined the manpower requirements of the project. A full­ time outreach worker was selected and a number of residents volunteered to be barangay service point officers. Manpower for the construction of a facility to house the project was also volunteered. Several residents

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volunteered to pick up the supplies from the Popcorn District Office every month. In addition, they promised to inform their neighbors who were unable to go to the meeting about the population project. The established community associations pledged active support to the project by promoting the family planning concept and available services in their monthly meetings. They also promised to join in the house-to-house campaigns. Association members shared valuable ideas on prospective resource mobilization schemes for the project based on their successful experiences at developing financial sustainability in other areas of village level cooperation. Popcorn and FPOP provided the resource personnel needed to train the community-selected full-time outreach worker and volunteer barangay service point officers. They also provided the supplies of contraceptives (e.g. IUDs and condoms), promotional materials (e.g. posters and leaflets), office logistics (e.g. record books and pens) needed to start up the project. In addition, Popcorn and the FPOP guaranteed a continuous supply of materials for the duration of the start-up project. The Department of Health contribution to the project was the use of a room inside the Barangay Health Station (BHS). The BHS was a perfect location to offer the family planning and other services because it was already a well-known place among community residents. Its central location was also very accessible to a majority of residents. Most of all, however, the Barangay Health Station offered a clean sterile location. It was also used as a weekly meeting place between the full-time outreach worker and barangay service point officers. This harmonious working relationship between key proponents and beneficiaries was a critical element to sustaining the services and activities of the Matabungkay population project after the withdrawal of support from the Popcorn and FPOP given the local resource constraints the project had. The implications of the Matabungkay projects local resource constraints will be expounded on in the succeeding sections of this case study. Methodological process. The methodological process of the Matabungkay Popcorn project was highly qualitative. Proponents and beneficiaries jointly undertook most of the planning, implementation, and sustainability activities of the project. The problem of inadequate and inaccessible family planning services vis-à-vis the growing married couple population had already been identified as a priority health concern by the community long before the arrival of the Popcorn and FPOP team. Thus, the actual identification of the problem was

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established by the community residents themselves. The only obstacle the barangay had was that they did not have the financial, managerial and technological resources to respond to this health care concern. The local municipal government, under which Barangay Matabungkay fell politically, informed the Matabungkay Barangay Captain that they did not have funds for such an endeavor. Hence when the joint Popcom-FPOP survey team for the Region visited the area, the Barangay Captain immediately informed them of the reproductive health care situation of the community. Armed with this reconnaissance report, the Popcom-FPOP survey team included Barangay Matabungkay in their list of prospective recipients for project resources from the province of Batangas. After the approval of an initial appropriation of resources was officially announced by Popcorn and FPOP, community beneficiaries and proponent representatives immediately set out to conduct a planning meeting to determine and prioritize action, benefits, and services within the community. Part of the agenda in this planning meeting w'as the selection of leaders and personnel for the project. In response to this, the group created a health care committee within the barangay to be chaired by the Rural Health Midwife assigned to the Matabungkay Barangay Health Station. With the help of this committee, the group established the criteria for (1) selecting the Full-Time Outreach Worker (FTOW) and (2) accepting volunteer Barangay Service Point Officers (BSPO). The Barangay Captain then called a community meeting where the duties and responsibilities of the two positions were explained to the village community stakeholders. Prospective applicants for FTOWs were nominated by the community residents, whereas numerous persons indicated their willingness to be trained as BSPOs. The background, intentions and expectations of each applicant was evaluated vis-à-vis the selection criteria established. Thereafter, the immediate project staff was selected. Training of staff and other personnel was dominated by experts from the Popcorn and FPOP. They informed the full-time outreach worker and the barangay service point officers of their roles and responsibilities in the project. The training staff implied in the sessions that it w'as up to their discretion to carry out added responsibilities as the project evolved. Management and administration of benefits, services, and action were carried out by the community selected FTOWs and BSPOs. In general, the outreach worker supervised and managed the day-to-day activities of the Matabungkay Population Project. The FTOWs was responsible for coordinating the field activities of the BSPOs which included determining the distribution of contraceptive supplies based on the information submitted by

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the later. FTOWs collected the data on acceptors and reconciled this information with the clinical files which they kept. The FTOWs assigned the BSPOs areas of responsibilities taking into consideration their familiarity with the location and the distance from their homes. The FTOWs received special training that certified them as resident family planning experts. FTOWs were also responsible for training new BSPOs. The BSPOs assisted the outreach worker in their field activities. As a team, they motivated and recruited family planning clients to the clinic and conducted surveys of prospective acceptors. They provided information about family planning and distribute oral contraceptives and condoms. Together, they also promoted other approaches to birth control like IUD insertions and sterilization. With the help of the FTOWs, the BSPOs maintained a record of married couples who were of reproductive age (MCRAs) and individuals who were contraceptive users. They also made home visits and follow-ups whenever necessary.Both BSPOs and FTOWs coordinated with field workers and staff members of the Department of Health. Project monitoring and evaluation was a joint effort between the GONGO project team, village community staff (FTOWs and BSPOs), and community beneficiaries. Once a week, the FTOW and BSPOs met to integrate information on new acceptors into a Barangay “population database”. Once a month, the outreach worker and service point officers discussed with the Popcorn and FPOP representatives the progress of the project. Demographic and other type of information were forwarded to the Popcorn and FPOP representatives by the field implementors. The Popcorn and FPOP representatives replenished the contraceptive and other logistical supplies of the project. According to a Popcorn representative interviewed, Popcorn also benefitted from the information exchange. For instance, they gained valuable feedback on herbal medicine and field perceptions on the overall population program itself, especially since the local Roman Catholic priest expressed critical views about artificial contraception in line with the pastoral letter handed down from the Archbishop. According to the Roman Catholic priest, only natural birth control methods, e g. abstinence and the rhythm method, were acceptable to the church. Crucial to project sustainability is the village community’s ability to mobilize local resources. The project was able to develop essential sustainability activities like the creation of a Matabungkay chapter of the FPOP, local resource mobilization schemes like user fees, the setting-up of coordinative linkages with the Department of Health, and donations from community NGOs. But these coordinative linkages and local resource

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mobilization schemes only covered the salary of the FTOW and certain logistical supplies of the project. A majority of resource mobilization still came from the central government sources. The physical infrastructure and contraceptive supplies came from Popcorn. During the two year start-up period of the Matabungkay project, the community was not able to gather enough funds to establish a clinic specifically for family planning services. Contraceptive supplies were too expensive for the Matabungkay community to continue handing them out for free or as mere token fees. After the withdrawal of resource support from Popcorn and the FPOP, the activities and services of the Matabungkay Popcorn project were slowly integrated into the primary health care activities of the Matabungkay Barangay Health Unit. In the meeting formalizing the end of the pilot project, the Matabungkay community expressed interest in sustaining the gains of the project beyond the pilot stage through their own resource mobilization activities. But this idea would only have been feasible if the central government (Department of Health) contributed the established resources of the Matabungkay BHS to help continue the family planning goal of the project. Community members thought that if the central government provided the financial and managerial resources for the family planning project through the larger Primary Health Care program, then they should let the government contribute to the sustainability of the project. The village community in turn would continue to provide whatever locally developed resource support they could give because, based on their assessment, community members believed they did not have sufficient community sources of resources comparable to what the government provided for the project. Besides this, the target beneficiaries believed that the continuance of the Matabungkay Popcorn project solely under the auspices of the community would only conflict politically with the Department of Health’s new mandate to include a family planning component to their rural health units. After hearing the arguments of the community and consulting with the Manila office, the central government agreed with the members of the Matabungkay community to employ permanently the former FTOPs and BSPOs of the Popcorn project. The Department of Health allowed the gains of the Matabungkay Popcorn project to continue in the Matabungkay Barangay Health Station with an expanded budget subsidy (Go, 1989). The Matabungkay Rural Health Unit was successful in sustaining the family planning behavior modification gains made by the initial start-up project. These included: (1) awareness of proper sanitation activities, (2) better spacing of children, and (3) birth-control practices. In addition, several

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status changes were also sustained by the Matabungkay Barangay Health Station with the active support of the community. These positive changes felt by the community were better reproductive health and the increased capacity o f married households to provide for their families with an appropriately planned and managed family size. The project’s community participation characteristics were instrumental in sustaining the project, but other external variables also contributed to sustainability, i.e. strong financial, personnel, and material resources from the national government. Under the combined efforts of the community beneficiaries, Popcorn and FPAP proponents, and the Matabungkay Barangay Health Station, the project was sustained for 12 years beyond the initial start-up phase in 1977-1978. Hanunuo Mangyan Health Project2 Participatory research in village communities. The structural decentralization period of the 1970s increased the government’s attention to rural village communities. This call for decentralization precipitated a corresponding increase in the number of rural health care delivery systems at the provincial, municipal, and village community levels. In addition, structural decentralization, deconcentrated authority and delegated managerial responsibility characterized these newly created administrative units. This increase in the number of rural health units and barangay health stations made it possible for the national government to reach areas that were previously unserved and enhance services in areas that were underserved in the 1950s and 1960s. Thus, creating local level Department of Health units, only meant that the same centralized planning and implementation system simply left the confines of the national government’s bureaucratic organization and was replicated in the country’s thousands of village communities. In the 1980s, another form of structural decentralization was introduced by the Philippine national government—privatization. This form of decentralization precipitated the creation of non-governmental organizations and private voluntary groups as an alternative approach to service delivery by the national government which were considered by many as ineffective and inefficient. As an alternative, non-govemmental organizations covered village communities which continued to be unserved or underserved by the government. The number of projects being implemented increased because of this growth in the number of governmental and nongovemmental service delivery systems. Unfortunately, based on the researcher’s evaluation of 38 Philippine health care projects, a large number

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of these projects were simply community-oriented (the blueprint approach as applied in the village-level) but were still not sustainable because of the lack of genuine local-level community management of the development endeavor. During the 1980s, emphasis was put on the process dimension of decentralization. Development experts envisioned that using more humanistic strategies would induce active collaboration, interaction, and involvement among all the groups involved in the project, which in turn would enhance implementation and increase sustainability. The application of participatory action research approaches thus blossomed in the village community level. In the Philippines, this participatory action research was elucidated in a model called Community Implementation and Planning System (CIPS) which became popular to both governmental and non-governmental organizations: It is an empowering process where the people decide, plan, and implement their design. The community members have to decide that they want to go through the process of getting information to help them in making a decision to improve the conditions in the community. From their decision, they plan out activities they would like to do and mobilize resources in terms of time, persons, and funds to implement the plan. The community is trained in research, planning, project implementation, and consultation facilitation. The system is viewed as cyclical process where the community does the research, planning, and implementation but the process starts again as soon as the community perceives the need for planning, research, and project implementation (Osteria, 1990, pp. 1718).3

Hanunuo Mangyan community. The Hanunuo Mangyan Health Project was one of these participatory action research projects launched by an NGO in the 1980s.The project was located in Barangay Binli in the Municipality of Bulalacao, province of Oriental Mindoro. According to a 1984 census, the Hanunuo Mangyans in Barangay Binli numbered around 1000 in approximately 150-200 households (Osteria, 1990). The average population density was 10 per square kilometer. This number was unevenly distributed ranging from 25 to 35 per square kilometer in some heavily forested and mountainous areas to less than five per square kilometer in more exposed locations (Osteria et al., 1988). The primary source of livelihood of the Hanunuo Mangyan community was subsistence agriculture. Their village’s farms produced a number of plants and trees—root crops, legumes, vegetables, fruit trees, bananas, rice and com. Shifting cultivation and food gathering were also main agricultural activities. There was an elementary school that services the

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educational needs of the children in the community. There are no community associations in Barangay Binli. There was no health station in Barangay Binli. The Bulalacao Rural Health Unit, the nearest government health facility, was not easily accessible to most of the Hanunuo Mangyans in Barangay Binli since they were spread out in a heavily forested area covering approximately 800 square kilometers. The most accessible health providers were the traditional healers. Several community volunteers had been trained by members of the American Peace Corps as community paramedics, while two villagers received health care instructions from the Programa sa Pagpaunlad ng Mangyan (Mangyan Development Program), a non-governmental organization. However, the health care training they received was mainly curative in nature (e.g. first aid) and not in the specific context of the Hanunuo Mangyan culture which needed a more preventive and community-based health care program (Osteria et al., 1988, p. 50). Health care status o f the Hanunuo Mangyan community. Earlier studies of the Mangyans in Mindoro all agree that the general state of health of the Hanunuo Mangyans was disappointing (Ellevera-Lamberte, 1983, pp. 63-69). This was exemplified by De La Salle Univerty Professor Trinidad Osteria’s description of the health situation of the whole Mindoro community: Without question, the Mangyans have poor health, are generally malnourished and are constantly faced with communicable diseases and threats of infection. At the same time, Mindoro island suffers from insufficient health facilities, resources and manpower. Consequently, the situation is bleaker for Mangyans since health services, particularly for those living in the hinterlands, are rarely available. If ever, health services are provided by missionaries and civic groups, although the majority of Mangyan settlements are not reached. The absence of doctors and hospitals as well as hygienic practices are responsible for the high mortality and morbidity rates observed among Mangyans. Despite growing acceptance of modern medicine, health facilities are non-existent in Mangyan communities (Osteria and Okamura, 1986, p. 153).

In the mid-1980s, a health and nutrition survey study conducted by community members and a team from De La Salle University (DLSU) found easily preventable diseases as the main causes o f illnesses in the Hanunuo Mangyan community. The top three causes of illness among males in Barangay Binli were: upper respiratory tract infection (70.4 per cent), dermatosis (59.3 per cent), and parasitism (43.2 per cent). The top three

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causes of illness among females in Barangay Binli were: nutritional deficiency (64.5 per cent), anemia (50.7 per cent), and parasitism (39.6 per cent). Aside from these diseases, fetal death was common. The community has a high fertility rate combined with a high mortality rate. For example, the average number of pregnancies was a high 6.7, whereas the actual number of live births was only 4.6. Fetal wastage occured to 13.8 per cent of all pregnancies (Osteria et al., 1988). Prenatal care was virtually unknown because 94 per cent of women had no health care or medical consultation during pregnancy. Dietary taboos were common. Most of the women did not introduce any special precautions to ensure a safe delivery (95.4 per cent of the cases). Deliveries occured at home with only the husband assisting. The umbilical cord was cut with what is readily available, e.g. cogon grass, sewing thread, bamboo stick, or bolo knife. Among those surveyed, 72 per cent said they used cogon grass. This figure was followed by those who said they utilized sewing thread at 14.5 per cent. The major causes of mortality among children were respiratory diseases (53.2 per cent), gastrointestinal disorders (15.2 per cent), malnutrition (10 per cent), and from malaria (9 per cent) (Osteria et al., 1988). The De La Salle University survey team’s report enumerates some of the environmental sanitation factors. Some of the significant findings of the report are: 68.6 per cent of those surveyed used dumping to dispose of their waste, 94.9 per cent used the bush as their toilet, and 75.4 per cent used open streams or springs as their main source of water. These glaring findings and accompanying statistical figures were compelling reasons for the De La Salle University team to do something about the situation in the Hanunuo Mangyan community. Organizational orientation. The Hanunuo Mangyan Health Development project was conceived by the De La Salle University Research Center (DLSU-RC), an academic non-governmental organization. De La Salle University received funding to assist the Hanunuo Mangyan Community from Canada’s International Development Research Centre (IDRC). The project duration was from 1985-1991. The project’s objective was to assist the Hanunuo Mangyan community in developing its own sustainable community health care system. The De La Salle University project team was guided by a participatory action research (PAR) approach and an integrated objective which looked at health care as only a part of an overall socioeconomic program (Osteria, 1986). The organization orientation of the project was highly decentralized. It started from IDRC to the actual Hanunuo Mangyan community-based

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health program. Unlike projects sponsored by governmental departments that are continuously under a tall hierarchical structure, the Hanunuo Mangyan Health Project had a flat structure from beginning to the present. Although there were discussions between the Bulalacao Rural Health Unit Staff and community residents, the Hanunuo Mangyan Health project did not receive much national government influence over the decisions and policies it formulated concerning the planning, implementation, and sustainability activities of the project. Degree o f interaction. The interaction between the DLSU-RC Team and the Hanunuo Mangyan project beneficiaries was active in character. According to Trinidad Osteria (1990), project team leader, the participatory action research approach was used as the intervention for the project because it is technically uncomplicated, clearly defined, short-term, and has no more than one objective. Three approaches were used to gather baseline data on the health and nutritional status of the Hanunuo Mangyan community. These approaches were: a household survey, a clinical assessment, and interviews with health service providers. The degree of interaction in these early approaches was mostly dominated by the proponents. However, the administration of the actual surveys and interviews was conducted by Hanunuo Mangyans themselves because very few respondents understood Pilipino (the Philippine national language), which was the language familiar to the DLSRC survey team. The most significant health care problems confronted by the Hanunuo Mangyan community were presented to them by their leaders and project team members. Highlights of the joint presentation were the following: •

Environmental sanitation: the lack of sanitary toilets, the absence of a potable water supply and improper storage of water result in the widespread incidence of diarrhea, skin disease and tuberculosis.

•

Lack of medical personnel and drugs.

•

Inadequate knowledge of curative and preventive health care that emanates from ignorance of the etiology of illness and from its subsequent improper management.

•

Lack of adequate prenatal care and sanitary deliveiy practices.

•

Poor nutritional status due to lack of food supply and improper dietary practices.

110 Development sustainability through community participation •

Lack of health care education (Osteria and Okamura, 1988, p. 231).

To follow up on these glaring problems, the project team and community members agreed to jointly conduct the research and implementation activities. Methodological process. The methodological process of the project was highly qualitative in approach. The DLSU-RC team started the Hanunuo Mangyan Health project with intense involvement and collaboration of the community members in the planning phase of the development endeavor. The team made sure that their ideas and viewpoints were given full consideration in the planning and design of activities. Both proponents and beneficiaries met in a general planning session which was held to develop an implementation plan for action and prioritization. The steps jointly developed by the DLSURC team and the Mangyan community during the meeting and subsequently carried out thereafter by both groups consisted of problem identification, determination and prioritization of action, benefits, and services, and personnel selection. These were more specifically accomplished in the following sequence: (1) discussion by the target community of the problem situation and issues arising from this situation; (2) community consensus about the health problems or issues; (3) selection of the core group responsible for the research cycle; (4) design of the project; (5) preparation o f the implementation and operation plan; (6) operationalization of the health plan; (7) joint data collection; (8) joint data analysis; (9) discussion of the operation’s problems; (10) development of change plans; (11) implementation of change plans; and (12) consolidation of learning. After the planning meeting with the De La Salle University Team, the Hanunuo Mangyans discussed the results of the survey and considered prospective solutions among themselves. A participatory process was also used in the recruitment and selection of the Hanunuo Mangyan community health workers. The main criteria utilized for recruitment and selection was the individual’s interest in serving the community through the health care program. Each volunteer health worker was presented to and approved by the community in a general meeting. Additional prerequisites used for screening the volunteers were their reading, writing, and understanding of Pilipino or the Hanunuo Mangyan language. Knowledge of either Pilipino or Hanunuo was important because the training sessions and training materials were written in the Pilipino. For those who could not comprehend the national language, a Hanunuo translation was provided. A majority of the community health volunteers were females (81

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per cent), whereas only seven were males. All of the volunteers had farming as their main occupations with the exception of one who was a high school student. Based on the results of the participatory research and planning phase, several services and activities were developed. The training manual was designed with participation from both the DLSU-RC project team and the Hanunuo Mangyans. It was based on a primary health care manual produced by the Department of Health. Translations first had to be done by the De La Salle University team into Pilipino because the Department of Health’s primary health care manual was written in English. The Pilipino version was then translated by the members of the Hanunuo Mangyan group into their native language. This group also integrated ideas based on their own traditional medical practices, especially in herbal medicine (e.g. preparation of bananas for the treatment of diarrhea, use of tamarind, ginger, and limes to develop cough syrup). The training manual was also very useful during the project’s implementation since it was a quick reference guide which reminded the Mangyan beneficiaries of the following: (1) concepts and goals of primary health care; (2) roles and functions of the village health workers; (3) maternal and child care, including pregnancy, childbirth and post-partum care; (4) family planning and (5) nutrition. Aside from these preventive and promotive topics, the manual had a section on curative and first aid instructions. Besides these, simple recipes for developing herbal medicine from available plants were included. The trainers for the project came from the Bulalacao Rural Health Unit. These were the public health nurse and the midwife. Their role as trainers was agreed upon by the community and project proponents since they had the specialized training based on their academic education and the Department of Health special courses on primary health care, microscopic detection and sputum examination. The DLSU-RC team presented the training manual to designated members of the Bulalacao Rural Health Unit during a two-day trainer’s workshop. The workshop familiarized the trainers with the specialized contents of the manual and provided them with tips on the teaching approach to be used. Thirty-seven Hanunuo Mangyan community volunteer health workers were present during the five-day training sessions for health workers, which included several traditional healers who became convinced of the need to expand their knowledge of health practices. In addition to these implementation activities, a Hanunuo Mangyan health care catchment area4 was constructed in a location decided on with ideas from both the DLSU-RC

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team and the Hanunuo Mangyan community members (Osteria and Okamura, 1988). The training was conducted with a combination of lecture, simulation, and hands-on approaches. For example, the volunteer health workers were taught how to collect sputum samples for tuberculosis detection tests and blood smears for malaria tests. They practiced applying the procedures they had just learned on each other. Part of their hands-on training was compiling a list of household members near their residences and constructing a pit latrine for the use of their families. After the five-day training workshop, the volunteer Mangyan health workers’ catchment areas were determined by the group based primarily on the location of their residence. The Hanunuo Mangyan volunteer health workers visited families in their areas on a regular basis. During their rounds, health workers identified the people in their assigned areas who were ill. If someone was ill, then they applied the appropriate treatment. Though health workers were supposed to be under the close supervision of the public health nurse, the volunteer health workers were seldom seen at the Rural Health Unit because of the distance of their areas of operation. Serious cases were brought to the Bulalacao Rural Health Unit to be attended to by the medical staff present. Aside from these curative services, the volunteer health workers had preventive tasks. They encouraged cleanliness and sanitation in their respective catchment areas. The volunteer health workers also mobilized residents to participate in emergency feeding programs, immunizations, and nutrition classes. In addition to these tasks, the volunteer health workers compiled and updated health records of each resident and assisted in the building of pit latrines beside each residence. In numerous formal meetings and informal discussions over lunch, the DLSU-RC team and the Hanunuo Mangyan community were also able to develop several activities towards sustaining the project. They organized health committees in each catchment area. Each health committee was composed of volunteer health workers, their spouses, community elders and other residents. The committees were composed of ten community members who were mostly men. Institutionalization of male participation in health projects was important since traditionally most rural community-based health care interventions were left to women. This was a critical behavioral change. One of the community elders chaired the health committee. The health committee provided the necessary channel for participation in the planning, implementation and maintenance of the health care project. In addition, the Hanunuo Mangyan community was able to develop

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an herbal garden, which help cut down on their dependence on expensive and frequently unavailable Western medicines. Savings from the use of herbal medicine were also complemented by simple supplemental income generating projects that were developed to support purchases of drugs when herbal medicine failed. These projects included basket weaving and fruit trees planting. Moreover, Hanunuo Mangyan barangay leaders offered to the project’s core group the use of a portion of their emergency and disaster revolving funds to start up various income-generating projects. Appropriate coordinative links with the Bulalacao Rural Health Unit were established with the active involvement of the rural health midwife and public health nurse in the training sessions. The community members and proponents were successful in carrying out these activities associated with the one year start up of the health development project (Osteria and RamosJimenez, 1988). Results o f the Hanunuo Mangyan health project. The Hanunuo Mangyan Health project resulted in the specific health care outputs enumerated earlier, i.e. training, technical, managerial, and financial capacity, and organization of members. Specific health care outcomes included behavior modification encouraging a concern for personal hygiene, community cleanliness, and male participation in health care activities. Specific status changes included a decrease in morbidity and an increase in life expectancy. According to DLSURC team members interviewed for this study, the project, the Hanunuo Mangyan Health Project, with predominantly community resources, provided these essential health care services, benefits, and activities five years beyond the withdrawal of the research proponents. The flow of participation and resources after the Hanunuo Mangyan Project’s start-up period was characteristic of local autonomous institution projects because it had high participation combined with mostly village community resources. As shown in the statistical analysis, these types of projects have a high degree of sustainability.

Negative Experiences Mindanao Schistosomiasis Project Department o f Health Schistosomiasis program. According to Philippine health economist Alejandro Herrin (1986), schistosomiasis is considered to be one of the most significant tropical diseases in the Philippines. Nationwide

114 Development sustainability through community participation surveys conducted by the Department of Health in December 1981 revealed that 150 municipalities in 22 provinces were infested with schistosomiasis. The areas of greatest infestation were Bicol, Visayas, and Mindanao. About four million Filipinos living in these areas have a high risk of contracting the disease. Over half a million people, most of them farmers and their families, are estimated to be already infected by the disease. Since the mid-1960s serious efforts have been undertaken to control schistosomiasis. Such control measures include: (1) health education, (2) proper sanitation, (3) control of the snail population and (4) monitored chemotherapy. Herrin (1986, p. 413) added that it is increasingly being realized that the success of various measures to prevent and control the disease depends upon a deeper understanding of the human dimension of disease prevention and control. In the Asian region, the most common form of schistosomiasis is caused by the worm called schistosomiasis japonicum (Katayama disease). Schistosomiasis affects 60 million people in the agricultural areas of Japan, China, the Philippines, Vietnam and Indonesia. In its early stages, schistosomiasis is characterized by abdominal pain, low grade fever, loose bowel movement and dysentry. In later stages, schistosomiasis symptoms are the enlargement of the abdomen and excruciating pains. Its intermediate host is usually a snail. As soon as the schistosomiasis parasite becomes infective, it leaves the snail and floats on the water up to the time it could find a more permanent host, i.e. humans or animals. Upon finding a permanent host, the schistosomiasis parasite enters the body by boring tiny holes in the skin. These tiny holes are also called skin eruptions, which are often very itchy. The accompanying scratching by the new host causes the allergic reactions typical among individuals who have come in contact with the schistosomiasis parasite while bathing, wading, washing, fishing in infected streams or rivers and farming in infected rice fields. Another documented source of infection is in the use of human excreta as fertilizer in vegetable gardens (Plorde and Jong, 1983, pp. 1217-1222; see also Mahmoud, 1977; Warren, 1978). Schistosomiasis was first given international attention as a critical health threat along with filariasis6 in the 1950s and 1960s when incidences in Asia and Africa grew to alarming proportions. In the Philippines, the result was the establishment of a Schistosomiasis Division and Filariasis Division in the Department of Health bureaucracy based in Manila. Schistosomiasis control was accorded more emphasis in the late 1960s with the creation of a ministerial advisory body called the Schistosomiasis Control Council, a body given similar importance and stature as the Philippine Medical Care Commission and Dangerous Drugs Board. This Council advised the Secretary of Health directly regarding the progress of efforts at controlling this disease

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nationwide. The structural decentralization decade of the 1970s led to the establishment of schistosomiasis control units at the regional, provincial, and district offices of the Department of Health. During the process decentralization decade of the 1980s, concern for the human side of this disease was intensified at the village community level, e.g. behavior modification and community awareness. Schistosomiasis projects funded individually and jointly by the Department of Health, United Nations Development Programme, World Bank, and World Health Organization Special Programme for Research and Training in Tropical Diseases increased in the Philippines. The Mindanao village community. The location of the Mindanao Schistosomiasis project was in Barangay Lubak in Davao del Norte. It is in the southeastern region of the main island of Mindanao. According to a 1981 census, Barangay Lubak had an estimated population of 1100 in 213 households. There was a public elementary school in Barangay Lubak but no high school. A majority of the population engage in agriculturally related employment, e.g. farming and livestock raising. The rest of the residents were permanent and casual laborers for a nearby multinational corporation engaged in fruit processing. There were no community associations in Barangay Lubak. Barangay Lubak was one of 35,000 in communities where there was no barangay health station. The health care necessities of the community were handled by a municipal rural health unit that provided a wide range of primary health care services, e.g. extended program on immunizations and family planning promotion. However, the municipal rural health care unit gave no preventive attention to the schistosomiasis problem in Barangay Lubak. Barangay Lubak led in the rate of incidence among the schistosomiasis-infected village communities in the Mindanao region. In a report by a regional survey team based on the number of snail colonies and extent of water contamination in the area, it was estimated that more than 70 per cent of the residents were infected. This was one reason why Barangay Lubak was listed as a priority area for project implementation by the Department of Health as soon as funds were made available. In 1984, funds were finally allocated by the national government for a schistosomiasis program in the Mindanao region. Barangay Lubak was selected as the pilot project. The Mindanao Schistosomiasis project is only one of a number of disease control projects being used by the national government to guide policy making in Manila. The project proponents

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included a government team composed of the Mindanao Schistosomiasis Control Unit of the region, the central office of the Department of Health, the Institute of Public Health and School of Economics from the University of the Philippines, and the Research Institute for Mindanao Culture from Xavier University. The objective of the project was to determine the following: (1) consequences of schistosomiasis on socioeconomic behavior and welfare at the individual, household and community levels; (2) sociocultural and economic factors influencing schistosomiasis transmission; and (3) demand for drug treatment and its sociocultural and economic determinants, particularly the price of services, and knowledge, attitudes and perceptions regarding the disease. This information would assist Manila-based health planners develop an accurate national policy for the control and eradication of the disease in the various regions in the country. Organizational orientation. The Mindanao Schistosomiasis project’s organizational orientation was centralized compared to the decentralized projects developed by a large majority of non-governmental organizations (e.g. DLSU-RC’s Hanunuo Mangyan Health Project) and a number of governmental organizations (e.g. National Population Commission’s Matabungkay Popcorn Project). The initial flow of health resources came from the multiple levels of governmental agencies involved in the project. In contrast to the two previous case studies (Matabungkay Popcorn project and Hanunuo Mangyan Health project) where the necessity for the project was established by the village community, demand for specific health care services of the Mindanao Schistosomiasis Project was determined and established by the health planners at the Department of Health head office in Manila. Degree o f interaction. The interaction between the proponent groups and village community beneficiaries was predominantly passive in character. Guided by the framework of two pilot schistosomiasis studies conducted in Samar (Lewert, 1979) and Oriental Mindoro (Carney, 1981), the proponent group designed a research agenda for the project. Health experts from the Department of Health dominated the discussion sessions for planning the disease control activities. Target areas were mapped and designated without input from the residents. Representatives from the government-run research institutions treated the community members as mere objects to be studied, which in turn would facilitate decision making in Manila. This was their interpretation of decentralization.

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The division labor among the Schistosomiasis Control Team of the Department of Health, Institute of Public Health-University of the Philippines, Research Institute for Mindanao Culture-Xavier University, Schools of Economics-University of the Philippines, and Central Office experts of the Department of Health was clearly outlined in the project document. Interestingly, there was no substantive role for the community residents in the implementation process except to act as respondents. Passive interaction ensued during the duration of the process because only the proponents knew what was occurring. A number of survey questionnaires were developed to extract information from the beneficiaries. This survey was divided into six general areas: (1) schistosomiasis prevalence survey, (2) household socioeconomic survey, (3) individual survey, (4) school performance survey, (5) community survey and (6) water contact survey. These area surveys collected information about social and economic demographics of household members, infected and non-infected adults, infected and non-infected children, key informants and location of snail colonies. The schistosomiasis prevalence survey was successful in collecting essential data on household members and their characteristics: (1) relationship to household head, age, sex, whether temporarily away or not, height and weight; (2) availability of blood-stool specimen and reason for non­ availability; (3) results of stool and blood examination to determine status of infection; and (4) among those found infected, results of follow-up physical examination. The household socioeconomic survey determined the following: (1) household composition and characteristics; (2) morbidity, health services use, and expenditures; (3) knowledge, attitudes and perceptions of respondents; (4) housing and sanitation; (5) household wealth and productive assets; (6) economic activities and income; (7) time allocation for home production, income-generating activities; (8) water contact activities; (9) schooling and educational expenditures and (10) rice crop production. The individual survey gathered information on disability, economic endeavors, and perception on schistosomiasis. The school performance survey determined information on infected and non-infected school age children. The community survey compiled data on population size, land area, transport facilities, health and environmental services, and community organizations. The water contact survey gathered information from key informants regarding perceptions on the prevalence of the disease, observation of individuals working in farms, washing clothes and bathing in infected areas (Department of Health, 1985; see also Herrin, 1986, pp. 416-418). Interaction between the proponents and beneficiaries during

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implementation was dominated by a one-sided question and answer procedure, i.e. members of the project team throwing out questions and the community members humbly responding. Methodological process. The methodological process of the project was highly quantitative in approach. The planning process was dominated by the Mindanao Schistosomiasis project team, which brought in representatives of the community to “inform” them of the project’s objectives. The schistosomiasis problem in the area had already been confirmed by both the regional experts and representatives from the Health Department’s Manila Office. The Department of Health sought to respond to the schistosomiasis problem with a national policy based on regional assessments by their expert staff. During a meeting with the community council of Barangay Lubak, the Department of Health’s project team assembled for the Mindanao area presented to them the problem, research methodology, and what the national government was planning to do. There was no involvement from the community during the prioritizing of action, benefits and services. Interest in the project was expressed by the village community with their representatives giving suggestions on how to make the project more effective from their point of view. Their suggestions were welcomed, heard and written down in the planning meeting’s minutes but were overshadowed by the preconceived plan of the schistosomiasis project team (Herrin, 1986). The personnel used for the project all came from the Department of Health including the experts, surveyors, data analysts, runners and laboratory technicians. Several community members volunteered to act as survey personnel but they were turned down by the project team. According to the project team leader, they already had sufficient personnel. The project team members added that what they were doing was too technical for any outsider to leam. The actual conduct of the project was dominated by the use of a survey research methodology and microscopic sample collection procedures. The Schistosomiasis Control Team of the Department of Health, technical experts from the Manila office, consultants from the Institute of Public Health-University of the Philippines were the ones who conducted the following activities: (1) area mapping, household listing, collection and examination of stool or blood specimens from each household member in the village community; (2) physical examination and drug treatment of infected individuals; and (3) surveys of snail colonies in the village community. Several members of the project team developed the socioeconomic

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survey questionnaire and application approach which was administered by the representatives from the Research Institute for Mindanao Culture-Xavier University. The Xavier University personnel were assigned this task because they already had prior experiences applying surveys in other Mindanao communities. Unlike most of the areas in Luzon and the Visayas, the Mindanao region has a predominantly Islamic culture. In addition, most of the Manila-based project team members were Christians who were unfamiliar with the intricacies of Philippine Islamic culture. The anthropological study on water contact activities was conducted by the Department of Health Manila Office representatives and Institute of Public Health personnel, while the school performance survey was conducted by an education specialist from Xavier University. Data analysis was conducted by the representatives of the School of Economics-University of the Philippines, Department of Health Manila Office, and Institute of Public Health-University of the Philippines. Their preferred procedure was dominated by health economics and econometric methods. During the implementation of the schistosomiasis detection procedures and surveys, the representatives from the Department of Health, Xavier University, and the University of the Philippines were so concerned with coordinating and compromising technical research issues among themselves that they again overlooked certain roles that community members could play in the implementation of the project, e.g. administration of surveys and data analysis. In the implementation meetings, all parties were again represented including the Lubak community, but the suggestions and ideas of the proponents almost always prevailed over the beneficiaries’ ideas. In these so-called community forums, the Barangay Lubak beneficiaries participated in the implementation phase of the project through their responses in questionnaires that requested demographic, behavioral, and other health care and needs information. These surveys became the basis for the health care activities aimed at eradicating schistosomiasis (e.g. sanitation workshops). The Mindanao Schistosomiasis Project was guaranteed financing by the central government for the duration of the pilot endeavor. The project was also provided with strong external managerial support by the Department of Health from the beginning to the end of the project. The community was never organized into action groups that would specifically handle the gains of the Mindanao Schistosomiasis Project once the Department of Health proponent team left. Lack of genuine interaction from the proponents and community beneficiaries led to two different interpretations of sustaining the project. On the one hand, the Mindanao Schistosomiasis project team overestimated the

120 Development sustainability through community participation community’s capacity to continue the project on their own after this start-up project. They based this assumption on the fact that the community members present during the planning meetings and “active” participants in responding to the health education meetings and surveys indicated local resource mobilization capabilities. On the other hand, the community got used to the managerial and financial support provided by the proponents, leading them to assume that the Department of Health (through the Davao rural health unit) would automatically continue to sustain the project beyond the start-up project endeavor. A change in the policy priority of the current administration from individual to more integrated Rural Health Unit-based Primary Health Care projects doused the community’s hope for central government resource mobilization, which they assumed would sustain the gains of the project (Herrin, 1986). Several Mindanao community members indicated that it was essential to sustain the project for an extended period of time, but they were not prepared to do so because of heavy reliance on government resources, absence of community infrastructure, and the lack of active interaction among community members and the Department of Health team members. Even though the community was planning to organize a health committee to support the project, they were not able to do so after the one-year project because this activity was not listed as a top priority in the organizers’ preconceived plan. Coordinative linkages between the community and national and regional agencies were established for the duration of the project, but this disintegrated with the departure of the proponent team. Results o f the Mindanao Schistosomiasis project. During the one-year duration of the pilot Mindanao Schistosomiasis Project, the proponents were able to emphasize the need for behavior modification to reduce the risk of disease transmission. This included the practice of personal hygiene, community cleanliness, use of safe water sources, and toilet facilities. Health-status changes were also achieved by the project in terms of a decrease in the incidence of schistosomiasis among community members. These health education activities and disease control services of the Mindanao Schistosomiasis project were not sustained after the initial start-up period. Shortly after the departure of the project team members, residents went back to their old ways of disposing of garbage and improper water usage. According to A. Herrin (1986), institutionalization of behavior modifications takes more time, which means a more learning process approach. The final substantive product of the project was a health status report for policy-makers and an academic publication. This final project

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report showed the one-year gains of the projects and recommendations for future policy. According to the researcher’s interpretation of the government report and the Herrin study, the Mindanao Schistosomiasis project team was not able to prepare the community to sustain the project because of the lack of active involvement and interaction between the proponents and beneficiaries during the planning, implementation, and sustaining processes and reliance on mostly central government resource mobilization. During interviews with officials of the Department of Health and the University of the Philippines, it was inferred that active community involvement in the decisions made during the planning and an ethnographic approach during the implementation of the project could have resulted in a more accurate interpretation of the local community’s needs. However, logistical support was also a key determinant in maintaining the project. Nueva Ecija Primary Health Care Project1 Philippine primary health care program. As part of their post-war development efforts, the Philippines-along with the newly emerging countries of the world, embarked on a modernization program heavily patterned after Western nations. This program led them to rapidly absorb the latest advances in medical technology in the Western world, neglecting the development of traditional health care practices. By the 1960s and 1970s, these lessdeveloped nations were feeling the dysfunctions associated with an over­ dependence on the Westernized approach to public health care. Several reasons were cited for the failure of the Western approach to medicine in the less developed countries: (1) The high capital requirements and recurring cost of maintaining a Western health system based on hospital-based care which resulted in an over- concentration in urban areas, serving only less than 20 percent of the total population; (2) The training and education of health professionals often alienated them from the people and prevented them from gaining a proper understanding of people’s needs. (3) The heavy emphasis on high technology and specialized care inherent in the Western approach resulted in the high cost of medical care, which rendered it beyond the reach of the majority of the population who lived below the poverty line.

122 Development sustainability through community participation (4) There was difficulty in availing themselves of foreign exchange for the importation of western equipment and spare parts. (5) The Western model tended to developed an illusion that Western drugs and medicine is a panacea for the health problems of mankind (Azurin, 1988, pp. 60-61).8 In 1978, the World Health Organization (WHO) responded to this global dilemma by adopting a strategy called Primary Health Care which was supposed to achieve sustainable health care for all until the year 2000. In 1981, under the “New Republic” of President Marcos, Primary Health Care was adopted as the nationwide strategy for health. As opposed to previous approaches, this strategy supposedly decentralized the responsibility o f sustainable health care down to the village community level. Five impact programs targeting urgent health concerns of village communities were the heart of Primary Health Care: (1) maternal and child health, family planning, nutrition; (2) tuberculosis control; (3) prevention and control of diarrheal diseases; (4) prevention and control of malaria; and (5) prevention and control of schistosomiasis. The Philippine Department of Health was able to provide additional budget subsidies for the start up of Primary Health Care projects in village communities which were designated as priority areas by the national government with funding from the UNDP, UNICEF, WHO, World Bank, USAID, and ADB. Barangay Zaragosa. The Nueva Ecija Primary Health Care project was located in Barangay Zaragosa in Nueva Ecija. This area is north of Manila in the main island of Luzon. Much of Barangay Zaragosa is swampy territory. Because of this swampy condition, a majority of the houses are elevated. According to a 1985 census the population of Barangay Zaragosa was 965 persons in 197 households. Barangay Zaragosa had a public elementary school. Sixty per cent of the income earners in the barangay are farmertenants, whereas 40 per cent were engaged in fishing related professions (e.g. fish vendors, fishermen, cargo handlers). There were four major village community associations in Barangay Zaragosa: (1) Mr. and Mrs. Association, a Catholic Church-initiated charismatic prayer group; (2) LUNAS, an organization initiated by the Department of Agriculture for fanners; (3) Sariling Sikap, an organization initiated by the Department of Social Welfare and Development to assist in part-time income generation and health care needs; and (4) Kabataang Barangay, the youth counterpart of the

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village community council. Before the Nueva Ecija Primary Health Care project, there was no Barangay Health Station (BHS) in Barangay Zaragosa. Health care services were provided by a traditional healer who specialized in assisting with the delivery of babies and faith healing. There was no private physician in the village community. The nearest private practitioner was 50 kilometers away. A majority of children below seven years of age suffered from some degree of malnutrition. Infant mortality from diseases were prevalent. Improper waste disposal was practiced. Before the implementation of the Primary Health Care project, the Department of Health in Manila had been planning the establishment of health care facilities in Barangay Zaragosa. Budget constraints during previous years did not allow them to push through with this plan although Barangay Zaragosa was in their priority action list. With the adoption of the Primary Health Care program in 1981, a budget for a Primary Health Care project in Nueva Ecija was appropriated. Being in the Department of Health priority list, Barangay Zaragosa was selected as one of the first beneficiaries. As stated in the Primary Health Care objective, the project was to provide an integrated range of preventive (e.g. immunizations), curative (e.g. consultations and referrals), promotive (e.g. family planning), and community organizing assistance to the target community. Organizational orientation. Just like the Mindanao Schistosomiasis project, the Nueva Ecija Primary Health Care project’s organizational orientation was centralized compared to the decentralized projects developed by a large majority of non-governmental organizations (e.g. DLSU-RC’s Hanunuo Mangyan Health Project) and a number of government organizations (e.g. Popcorn’s Matabungkay Population Control Project. Unfortunately, both village level beneficiaries and proponents needed to pass through a complex level of national and local governmental agencies before critical health care services and resources reached them. Although it was perceived that after the initial outpouring of funding the community would be able to sustain the gains of Primary Health Care through community resource mobilization, in a majority of Department of Health-initiated Primary Health Care projects this never happened. Primary Health Care projects started in the early 1980s continued to be sustained by national government manpower and financing up until the early 1990s. In the case of Barangay Zaragosa, the national government’s role was to coordinate community participation towards the project. However, the national government was not responsible for mobilizing resources after the formal

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departure of the Department of Health Primary Health Care project start-up team. Much of the Primary Health Care program banked on barangay health workers (BHWs) because they were the ones who actually went out to the field and administered the services. A very common case was that once the BHWs have been selected and trained they considered themselves to be extensions of the DOH. The researcher observed that in a majority of the government-initiated primary health care projects, BHWs shifted allegiance away from the community to the Department of Health. The BHWs believed that they were employees of the Department of Health. Hence, they thought that they would eventually be integrated into the health bureaucracy and be given pay from the national budget. As conceived by Primary Health Care, this was not the purpose of BHWs. It was envisioned that the BHWs would eventually be integrated into the barangays. The barangays and not the national government would purchase medical supplies and provide for their renumeration. However, at the time of evaluation the barangays lacked the necessary capability to compensate for the BHWs’ services and purchase their logistical requirements. Therefore, the BHWs remain loyal to the national government for the training, benefits, and medical supplies they are given. Degree o f interaction. The interaction between proponents and beneficiaries groups was passive in character. The DOH team dominated all decision­ making sessions pertaining to planning, implementation, sustainability. Community residents through their barangay officials convened a barangay assembly open to all and determined the manpower requirements of the project. A large number of residents volunteered to be BHWs. Manpower for the construction of a facility to house the project was also volunteered by Barangay Zaragosa residents. In addition, several residents volunteered residences as temporary catchment areas while the main health station was being built. In addition, they promised to inform their neighbors who were unable to go to the community assembly about the primary health care project. The decisions regarding the need for the project itself, however, and the actual implementation of the project were dominated by the DOH personnel. The community associations pledged active support to the project by promoting the primary health care concept and available services in their monthly meetings. They also promised to join in the house-to-house campaigns. Association members shared valuable schemes on prospective resource mobilization schemes for the project based on their successful

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experiences at developing financial sustainability. They also donated initial start-up money towards the project. However, though most of their suggestions were recorded the national Primary Health Care plan was still the blueprint used during the field level implementation of the Nueva Ecija Primary Health Care project. Moreover, not all residents were supportive of the primary health care project. There were those who believed that curative care was what they needed in Barangay Zaragosa. These dissenters wanted the government to establish a clinic with a public health doctor present on a weekly basis. Collection of the user fees from the community was also an issue because one group argued that a “neutral” person from outside the barangay should do the fee collection and administration. There was evidently mistrust among certain persons in the target community because of bad experiences in previous development projects. In the end, the Public Health Midwife, who was appointed by the Department of Health, took charge of collecting and managing the user fees and other financial matters pertaining to the project. The DOH provided the resource personnel needed to train the Barangay Health Leaders (BHLs) and BHWs. They also provided the primary health care promotional materials (e.g. posters and leaflets), office logistics (e.g. record books and pens), and medical supplies (e.g. drugs, weighing scales, oresol) needed to start-up the project. The Department of Health project team guaranteed a continuous supply of materials for the duration of the start-up project. Methodological process. The methodological process of the project was highly qualitative in nature. The Nueva Ecija Primary Health Care project’s planning sessions were designed to approve the preconceived plan handed down by the DOH central office. The problem of the village communities and in effect the Nueva Ecija Primary Health Care project had already been defined nationally. This national Primary Health Care plan assumed the critical need for preventive, promotive, and curative services. Members of Barangay Zaragosa “participated in the discussions” sponsored by the proponents by providing baseline information for the use of health experts. The role of the Zaragosa beneficiaries was to be recipients of policy handed down by bureaucrats from the central offices. The national Primary Health Care program was still the main basis for planning, determination, and prioritization of specific project activities, benefits, and services. As mentioned earlier, the national Primary Health Care policy emphasis was on the following five impact programs: (1) Tuberculosis Control (TB); (2) Malaria Control; (3) Comprehensive Maternal and Child

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Health (MCH); (4) Control of Diarrheal Disease (CDD); and (5) Schistosomiasis Control. Prevention and control of the diseases associated with these five impact programs were embodied in a training manual used nationally to train BHLs and BHWs (see Ministry of Health, 1983 and 1985). Numerous individuals volunteered to be active personnel for the project. These individuals were screened by the start-up project team. The project team selected those who fit their criteria and presented them to the community for approval. No community member was involved in this selection process. The community, afraid of losing the project, never objected to the process of selection used. During the initial planning session, the community was informed that the DOH would finance materials for the needed health station if the community would provide the manpower and resource mobilization scheme to maintain it, i.e. income-generating projects, community donations, and user fees. Again, the community had no choice but to agree and do their best. Fortunately, several volunteers were gathered to construct the health station, while several community groups pledged to provide start-up capital and other resource mobilization schemes. According to interviews with outside evaluators, who monitored and evaluated the conduct of selected meetings between the project proponents and the community, the DOH Primary Health Care experts (physician or public health nurse) were visibly the ones dominating and benefiting from the discussions. Zaragosa community members were present in the meetings only by invitation of the health professionals (Bautista, 1989a). This domination and at times cooptation (especially of the BHWs) emphasized the low degree of participation that characterized the planning and implementation processes of the Nueva Ecija Primary Health Care project. The Zaragosa village community and Department of Health workers actively collaborated and interacted in several important implementing activities. A high participation activity of the Nueva Ecija Primary Health Care project was in the selection of BHLs and recruitment of BHWs which was a joint effort between community residents and the project proponent team. In addition, several residents showed their active interest in the success of the project by volunteering their homes as temporary catchment centers. After the project’s training sessions conducted by the DOH, the BHLs and BHWs excitedly carried out their initial practical training health activities (e.g. sanitation advice and safe water-storage demonstrations). The project team from the DOH guided the new BHWs in their implementation of the five impact programs thoughout the start-up period of the Nueva Ecija Primary Health Care project. The project proponents, however, were still the main administrators of project services, benefits, and

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activities. As cited earlier, Barangay Zaragosa BHWs began to act as employees of the DOH instead of the village community. Hence, their implementation of the five impact programs was only carried out to fulfil the requirements of their jobs as outlined by the Department of Health and not because the community needed the Primary Health Care services, activities, and benefits. A Barangay Primary Health Care Committee was established to help identify the health needs of the barangay, manage and monitor community health care, and mobilize local resources. However, this committee was never able to influence the overall policy decisions of the Primary Health Care program. Local resource mobilization was never carried out by this committee during the start-up project—a critical component of any development project. The DOH and their BHWs implemented the Primary Health Care activities with little involvement from the residents of the community. In fulfilling the Tuberculosis Control Program, the Nueva Ecija Primary Health Care project team mobilized and trained BHWs in case finding, treatment, follow-up, and TB drug distribution. During the Malaria Control Program, the DOH-led project team and BHWs conducted: (1) residual spraying of selected houses in endemic areas; (2) clearing of breeding places; (3) intensive case findings; and (4) preventive health care follow-ups. In pursuit of the Comprehensive Maternal and Child Health Program, the project team introduced family health record keeping (e.g. birth, incidence of illnesses, death, and nutrition) for an accurate and updated health information system. During the Control of Diarrheal Disease Program, the project team encouraged the use of less expensive oral rehydration therapy (ORT) for disease management, promotion of safe water supplies, proper waste disposal, food sanitation, nutrition promotion, and breastfeeding tips. During the Schistosomiasis Control Program, the Nueva Ecija Primary Health Care project developed the BHWs’ case finding abilities, treatment, and follow-up of schistosomiasis incidence. Project monitoring and evaluation was conducted by the project team members who represented the DOH Manila office because they needed to provide feedback on the success or failure of the larger program for the use of policy makers in the central office. Very little beneficiary and proponent interaction existed during the sustaining activities of the project because of the dominance of the DOH experts. The creation of the Barangay Primary Health Care Committee as a health care action group and advocate of the community never had a significant impact on the sustainability of the project. The creation of costrecovery mechanisms was a condition imposed by the DOH and conscientiously adhered to by the community. The BHWs who were supposed

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to be the link between the community and RHU owed more allegiance to the DOH than the community they were supposed to represent because the barangays never gave them direct compensation. The DOH asserted itself in the project by establishing the needed physical infrastructure—the Barangay Zaragosa Health Station. DOH personnel also acted as the financial manager of the primary resource mobilization scheme, i.e. proper collection and allocation of user fees. The Rural Health Midwife assigned to the Barangay Health Station needed to coordinate management of the fees due to disagreements among beneficiaries regarding who to trust in allocation and collection. Previous project experiences where some community members mishandled money had polarized Barangay Zaragosa into several factions. Without conscientious efforts by the community as a whole to settle these problems, a sustainable process was impossible to initiate. Results o f the Nueva Ecija primary health care project. The Nueva Ecija Primary Health Care project was able to institutionalize numerous behavior changes in the areas of community sanitation, consistent health check ups, child immunization, and nutrition consciousness. However, this was due mainly to strict rules and regulations imposed on the community by change agents from the central government. Moreover, financial and other forms of support came predominantly from the DOH with very little coming from the community. Status changes felt by the community were a decrease in morbidity and a decrease in malnutrition. Despite the low degree of beneficiary and proponent collaboration and interaction in the planning and implementation of the Nueva Ecija Primary Health Care project, it was sustained for five years beyond the start-up period. Participation in the health care services and activities of the Nueva Ecija Primary Health Care project was characterized by a passive interaction approach and a top-to-bottom organizational structure of the DOH through its Nueva Ecija surrogate—the Barangay Zaragosa Health Care Station which made sure of sufficient community-based resource mobilization, i.e. user fees, community donations, and other income­ generating projects (Alfiler, 1986). The flow of support after the Nueva Ecija Health Care project’s start-up period was typical of central government department and local community unit linkage. The Philippine Department of Health now includes the activities of this community-based program in its annual operating budget.

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Summary of Findings These in-depth case studies representing varying sub-national communitybased projects reinforce the conceptual and empirical assertions made by various scholars and practitioners in the previous chapter. It basically shows a mixed bag of experiences from the Philippine health sector. Not surprisingly, one case, the Hanunuo Mangyan project provided strong support for the conventional assumption that community participation is quite critical to project sustainability. However, as pointed out in chapter two, other factors also play strong supportive roles and may be equally important to the projects. This was clearly illustrated by the Matabungkay Popcorn Project. Various experts from all over the world also explained that in certain projects community participation will play an important role while in others it will not. In some health development projects, other internal and external factors will be more critical to development sustainability as demonstrated by the Mindanao Schistosomiasis Control Project and the Nueva Ecija Primary Health Care Project. The next chapter concludes with an integration of all the findings from the study, including some implications for both policy makers and researchers. Notes 'information for this case study was based on an evaluation of Go (1989), documents provided by the De La Salle University Research Center and the National Population Commission (Popcorn), and interviews with several members of the Matabungkay Barangay Health Station and community residents, information for this case study was gathered from the following in depth evaluations: Ellevera-Lainberte (1983), Osteria and Okamura (1986), Osteria and Okamura (1988), Osteria and Ramos-Jimenez (1988), Osteria et al. (1988), and Osteria (1990); interviews with members of the De La Salle University Research Center Team; and an interview in Singapore with Trinidad S. Osteria, project team leader, who was then based at the Institute for Southeast Asian Studies (ISEAS). 3Similar observations were made by Polistico (1988). 4Temporaiy place in each assigned area where immunizations, weighing-ins and consultation were conducted by the health workers. information on this case study was based on Herrin (1986) and interviews with several members of the Mindanao Schistosomiasis Team who were based at the Department of Health Main Office in San Lazaro, Manila and the University of the Philippines, Diliman, Quezon City in 1990. ®Filariasis is a health disorder produced by infection with nematodes of the superfamily Filiarioidea. Filariasis manifests itself as threadlike worms that use

130 Development sustainability through community participation various types of mosquitoes as intermediate hosts. After their transfer to the permanent host, these worms invade the lympathics and subcutaneous and deep tissues of humans producing reactions ranging from acute inflammation to chronic scarring. More than 250 million people throughout the world are infected with this health threat. Regions at high risk are Africa and Asia (Plorde, 1983, pp. 12141217; see also Neva and Ottesen, 1978; Nelson, 1979). information for this case study was based on Bautista (1989a) and interviews with residents of Barangay Zaragosa, members of the Nueva Ecija Rural Health Unit and Department of Health officials. 8Similar arguments were presented by Biyant (1969).

Conclusions Based on the empirical evidence presented in the previous chapters, both from the Philippines and other countries, this book concludes with a verdict on whether development sustainability can really be assured with community participation. It highlights findings from the project experiences gathered as well as the project cases examined in-depth. It also reveals some conceptual and policy constraints on which present and future public health care managers, facilitators, policy makers, and providers from the community, national level, and international organizations like the World Bank, UNDP, WHO should reflect. From a careful analysis of the Philippine cases and the numerous global experiences extracted from the massive development literature that community participation does not just happen. It is definitely a group action that must be organized carefully if it going to the key to development sustainability. Whoever manages the effort must also understand the design sequence, identify critical points where participant information is needed, decide on the timing of activities and select the methods to be used. All of these must, in the eyes of the participants, amount to something tangible as the effort proceed and is sustained. This requires making all stakeholders’ contributions visible, documenting and reporting progress, and revising the tasks as new information or issues appear and original task elements become irrelevant or redundant. For many community members the practice of project design and implementation is an obscure, unknown, and little understood activity. One element which can facilitate individual participation is a well-defined outline of the anticipated project process. This should include a goal statement, target dates, explanations of the sequence of activities, definitions of outsider official roles and resources, and the kinds of activities and benefits to be handled by community members. This information conditions expectations of what is to come and allows individual participants to introspect and judge how she/he might fit in, what might be contributed, and the extent of personal involvement. Such clarity helps to create the environment of participation. Despite the negative views, community participation will continue to be one of the most sought-after preventive and curative recipes to ensure 131

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development project success, whether measured in terms of effective program implementation or long-term project sustainability. As some of the optimists argued, community participation should not just be viewed as a means but also an end in itself. This is a major reason why it becomes a factor to sustainability. However, one of the lessons from the case experiences presented here is that development scholars and practitioners must not be too quick to discount other equally important internal factors to success, especially local resource mobilization, institutional capacity building, and effective community management. Furthermore, some macro political and economic variables can also make or break a project. Additionally, some development projects need more community support and involvement than others, as correctly pointed out by some of the skeptics and pessimists based on their investigations. Hence, in actual practice, disregarding the significance of these endogenous and exogenous dimensions of a project could also lead to the non-sustainability or failure of development.

Does Community Participation Really M atter to Sustainability? Based on the health care projects examined in this study, the response seems to be mixed—yes, in most cases but surprisingly, not necessarily so in others. The case experiences demonstrate that the likelihood of sustainability is greater for three of the four project types: the Hanunuo Mangyan Health, Matabungkay Popcorn, and Nueva Ecija Primary Health Care projects. According to the evaluations, the first two, the Matabungkay Popcorn and Hanunuo Mangyan projects showed a strong likelihood of sustainability because of the institutionalized arrangements that facilitated high community participation in the planning, implementation, and maintenance of the project, especially at the local level. This essentially means that Philippine health care projects with high community participation characteristics combined with either village community or central government resource support are more likely lead to sustainability. However, the Nueva Ecija Health Care project also showed that health care projects with low community participation but complemented with mostly village community-based financial resource support handled by the appointed central government representative also have a strong possibility of being sustained. The case of the Mindanao Schistosomiasis Project which had strong central government direction, however, proved less ideal for project sustainability. This project illustrates that low community participation characteristics combined with mostly central government resource support will could lead to non-sustainability.

Conclusions 133

The Hanunuo Mangyan Health and the Mindanao Schistosomiasis cases provide the most support for the affirmative opinion that community participation is the key to sustainability, over and above other internal and external variables. The Hanunuo Mangyan Health Project demonstrates how an activity with high community participation characteristics will most likely result in sustainability. In the project, participation was both a means and an end to achieving sustainability. Furthermore, the Mindanao Schistosomiasis Project reinforces the optimists’ affirmative argument by showing how a project with predominantly low participation characteristics will most likely result in nonsustainability. These two projects also imply that health care development, even with solely the necessary internal and external determinants of sustainability, will not be sustained without active beneficiary and proponent collaboration, interaction, or involvement. However, the Matabungkay Popcorn and the Nueva Ecija Primary Health Care Projects provide the most support for the skeptics and pessimists’ negative views that external and internal variables could be as critical to sustainability as the degree of proponent and beneficiary interaction and collaboration. The Matabungkay Popcorn case illustrates the importance of participation to the sustainability of a project, but it also shows how central government resources, through the RHU, can be as critical to sustainability as participation. In addition, the Nueva Ecija Primary Health Care Project demonstrates how an endeavor with low participation can still be sustained especially with abundant community-based resources. In the Matabungkay Popcorn Project, political commitment by the central government brought into the project the resources necessary for long-term sustainability (e.g. financial and managerial support).

Im plications

Application implications This study also finds that there is a critical difference between going through the empty ritual of participation and having the real power needed to affect the outcome of the process. Community participation without redistribution of power is an empty and frustrating process for the powerless of any society. It allows the power holders to claim that all sides were considered, but makes it possible for only some of those sides to benefit. It tends to maintain the status quo.

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In an attempt to cut across both the euphemisms and the rhetoric of community participation found in the voluminous literature reviewed, this study recommends the use of the following typology developed by Sherry Amstein in 1969. This typology helps clarify various degrees of participation that can be introduced or induced in a development project—from pseudo to real participation (See Gonzalez and Mayfield, 1995):1 Level 1: Pseudo participation . In the name of people participation, members

of a community are allowed to assemble for the express purpose of “educating” them or engineering their support. In such a meeting, it will be the officials who educate, persuade, and advise the citizens, not the reverse. The purpose is to manipulate the people into accepting some government program, some policy condition, or some new requirement of a central ministry. These meetings are often described in the high-sounding rhetoric like “grassroots participation”, local involvement, or people participation. Level 2: Information sharing. Informing community members of their rights,

responsibilities, and options can be the most important first step toward legitimate people participation. However, too frequently the emphasis is placed on a one-way flow of information (need for shared awareness communication)—from officials to community members—with no channel provided for feedback and no power for negotiation. Meetings can also be turned into vehicles for one-way communication by the simple device of providing superficial information, discouraging questions, or giving irrelevant answers. Level 3: Consultation. Inviting community members’ opinions, like sharing

information, can be a legitimate step toward their full participation. But if consulting them is not combined with other modes of participation, this rung of the ladder is still a sham since it offers no assurance that common people’s concerns and ideas will be taken into account. The most frequent methods used for consulting people are attitude surveys and community meetings. When government officials restrict the input of people’s ideas solely to this level, participation remains just a window-dressing ritual. Level 4: Placation. It is at this level that citizens begin to have some degree

of influence through tokenism is still apparent. Examples of this type of participation include program planning committees where a few carefully picked community members are allowed onto the committee. If they are not accountable to the community itself and if the traditional power elite or

Conclusions 135

government officials hold the majority of seats, the disadvantaged of the community can be easily outvoted. Another form of placation is to allow a community based council to advise and plan ad infinitum but retain for government officials the right to judge the legitimacy or feasibility of the advice. Level 5: Partnership. At this rung of the ladder, power is in fact redistributed through negotiation between citizens and officials. They agree to share planning and decision-making responsibilities through such structures as joint policy boards, planning committees and mechanisms for resolving impasses. After the ground rules have been established through some form of give-andtake, they are not subject to unilateral change. Partnership can work most effectively when there is an organized power-base in the community to which the selected leaders are accountable to; when the community group has the financial resources to pay its leaders reasonable honoraria for their time-consuming efforts; and when the group has the resources to hire (and fire) its own technicians and community organizers. With these ingredients, community members have some genuine bargaining influence over the outcome of the plan. In most community development efforts, where meaningful participation has been established, power has come to be shared with initiatives and responsibilities taken by the members, not given by the officials. Thus a true partnership is often stimulated by angry community leaders demanding an equal share of the process of decision. There is nothing new about this process, which is often characterized by hostility and rancor. Since those who have power normally want to hang onto it, historically it has had to be wrested by the powerless rather than proffered by the powerful. Level 6: Delegated power. Negotiations between community leaders and government officials can also result in communities achieving dominant decision-making authority over a particular plan or program. At this level of participation, community leaders and their members are actually given the resources and authorities needed to implement a given government program and thus become accountable themselves for the success of the program. Central officials tend to play the role of auditor to ensure the project is implemented according to certain standards of operation. Level 7: Community autonomy. In many developing country societies, demands for community controlled schools, health clinics, and village development programs are on the increase. Community members are simply

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demanding greater autonomy and authority which guarantees that home grown institutions can govern a program or project, be in full charge of policy and managerial aspects, and be able to negotiate the conditions under which “outsiders” may change them. A village council or development center at this level of participation can take the initiative to mobilize their own resources through user fees, local taxes, community donations, etc. Moreover, community members can seek to establish and maintain solid linkages to other valuable resource providers. The typology presented here suggests the various ways that community participation can be defined and implemented. This study shows that community participation as defined at the highest levels (5-7) of the participation ladder were found to be much more effective in supporting project effectiveness and implementation.

Conceptual Implications In the 1950s and 1960s, planned development’s centralized approach and Weberian-inspired organizational arrangements did not lead to sustained village community health care. In the 1970s, decentralization was promoted as the key to achieving sustainability. Unfortunately, structural decentralization provided development administrators with only part of the solution. By reorganizing the bureaucracy, project implementation was facilitated at the village community level but long-term sustainability was still not achieved in most cases. In the 1980s, another dimension to decentralization was introduced with the emphasis on process and human behavior. Development management experts saw the prescriptions associated with process decentralization as an additional facet to achieving sustainable health care at the village community level. Combining community participation and local resource mobilization became the critical buzz word o f this decade. Unfortunately, the results of the case study analyses show that not all decentralized projects automatically attain project sustainability. Even in the decade where development sustainability was emphasized, the centralized system to health care delivery still exists. In certain projects, structural decentralization still tended to create administrative systems characterized by a form of centralized top-to-bottom decision making and to maintain a fairly tight control over resource allocation that passed through regional, provincial, municipal checkpoints before reaching the village community. The national

Conclusions 137

government must seek to become an agent of sustainability by encouraging local participation and resource mobilization at the village community level in order to leverage central government funding in the most efficacious way possible. From the literature research for this study, it is clear that the use of process decentralization can generate village-based institutions of sustainability. The results of the analyses show that both centralized and decentralized village community health care projects can achieve sustainability when there is a coordinated interface linking community participation, local resource mobilization, and effective government support or encouragement. In an attempt to analyze various approaches to the question of sustainability, four types of village community health care projects were identified: local community-initiated (high participation and mostly village community resource mobilization), state and community-linked (high participation and mostly central government resource mobilization), national bureaucracy-coordinated (low participation and mostly village community resource mobilization), and politician and bureaucrat-favored (low participation and mostly central government resource mobilization). The greatest chance of strong sustainability was illustrated by the state and community linked projects (100 per cent) and local autonomous institution projects (85 per cent)—both of which sought to integrate local resource mobilization, community participation, and effective government support. The case study on the Matabungkay Popcorn project illustrates the participation and resource mobilization processes involved in a state and community linkage project, while the Hanunuo Mangyan Health project demonstrates the participation and resource mobilization approach used in a local communityinitiated project. Thomas Bossert (1990) speculated that external factors, being relatively fixed and not subject to the control of the project beneficiaries, could be the more critical determinants of project sustainability or non­ sustainability, rather than participation. The Philippine health care sample, however, demonstrates that a higher degree of community and proponent collaboration and interaction increases the project’s ability to survive and be sustained when there is active local resource mobilization. The statistical analyses of the 38 projects and the case study analyses of the four representative projects suggest that when there is a high degree of beneficiary and proponent collaboration, interaction, and involvement, the project is more likely to be sustained, but only when the community is willing to mobilize some of its own resources. The optimists’ emphasis on strong beneficiary and proponent involvement and collaboration, combined with the skeptics’ proposal to

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concentrate on the internal and external factors, have inspired the researcher to propose the enhanced conceptual arrangement. This revised conceptual framework merges the two areas highlighted by the proponents of the affirmative and negative views, i.e. community participation in combination with the internal and external factors akin to the health care project are all key to project sustainability. Moreover, it adds a new dimension, which is stressed in the Philippine sample. The findings of the study emphasize the role of participation as a direct catalyst not only of sustainability but also of a more effective use of village community-based or central government-provided resources. As a means, community participation can be viewed as a muchneeded continuing process wherein initially stakeholder involvement is used as the essential harmonizer of ideas, suggestions, and action by bringing together the interests of the proponents and beneficiaries in meetings and discussions on how to mobilize and use resources. Thereafter, stakeholder enthusiasm and commitment becomes the essential glue that makes the community succeed in any development endeavor they implement. Adequate financial, material, and personnel resources themselves are direct facilitators of sustainability and these cannot be harnessed without participatory development. However, as emphasized in this study, community participation alone cannot insure that the presence of these essential internal and external ingredients of development will automatically lead a project towards sustainability. As an end, participation ensures that the successes attained during the pilot project are sustained for an extended period of time by making sure that the interaction, collaboration, and involvement used in the planning and implementation of the project are institutionalized to continue the endeavor beyond the start-up phase. In essence, this study demonstrates that sustainable development through a participation and resource mobilization interface can be considered both participation in development (means) and participatory development (end). Heavy decentralization and devolution is now occurring in the Philippines with the passage of the Local Government Code of 1991. However, there is a need to re-examine seriously key issues pertaining to local leadership, local level capacity building, and stakeholder participation in the ensuing development processes. This configuration will greatly affect the degree of community involvement in all types of development projects from the national to the sub-national levels.

Conclusions 139

Policy Implications The locus of analysis highlighted in this study was the barangay or village community level in the Philippines. The village community in the Philippines is seen as the core of the rural peoples’ empowerment (Alfonso, 1986). Emphasizing this understudied area has also highlighted the importance of appropriate linkage mechanisms between the nation-state and international entities vis-à-vis village communities in ensuring sustainability. Several projects in the study (e.g. Matabungkay Popcorn, Binan HMO, Laguna USAID-Primary Health Care) stressed the need for coordinative and collaborative linkages not only among the proponents and beneficiaries of the immediate project but also with actors from the nation­ state (municipal up to the national government) and international levels (international organizations concerned with health, e.g. WHO, and development, e.g. UNDP). The health care projects in this study showed that external project linkages are as critical to sustainability as internal project cohesion. No matter how stable a community project is, it still needs to work with the rural health unit which represents the national government at the village level. The RHU may then be connected to the other levels of government and eventually to international agencies. In some projects, direct coordination and collaboration with the rural health unit insures a continuous flow of financial, managerial, and institutional resources from the state or international donors, which sustain the project way beyond the start-up endeavor (e.g. Nueva Ecija Popcorn project). In other projects, relationships between the state and village project are more indirect. Indirect coordinative and collaborative linkages means recognizing and involving the members of the village project in activities which share ideas, suggestions and feedback on: (1) advances in health care and management techniques; (2) implications on the project of policy shifts and administrative changes; and (3) monitoring and evaluation activities performed on the projects (e.g. Hanunuo Mangyan, Katiwala, and Bagong Silang projects). International health organizations provide similar forums for health concerns but this time at the global level. Due to technological advances in transportation, communications, and environmental science, members of the world community are beginning to believe that development efforts in village level communities are not immune from the prescriptions of international conferences. For example, the primary health care mandate of the Alma Ata conference in the Soviet Union has benefited even the most remote and primitive tribal community in the Philippines—the Hanunuo Mangyans of Oriental Mindoro. In turn, the lesson from the application of primary health care techniques to this tribe has

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helped shape participatory anthropological practices all over the world (see Osteria 1990). Hence, although the village community seemed to be the ideal level of analysis for sustainability studies, appropriate concern should also be accorded to the coordinative and collaborative linkages to state and global actors. Development researchers and practitioners could replicate ideas from the simple analytical framework developed in this study for evaluating the relationship between the central government and the village communities in countries which may have similar health care contexts, e.g., Indonesia, Peru, and Kenya. Many of these countries have basically the same pattern of development regarding their health care systems - first a centralization of planning approach, then structural decentralization through reorganization, and currently the use of process decentralization and sustainable primary health care. The findings of this study could stimulate scholars in other countries to empirically verify if the relationship among the cited variables also exist in other parts of the world. The analytical framework and findings of this study could also be used to evaluate the sustainability of projects in the Philippine agricultural, social services, cottage industry, and rural infrastructure sectors. For example, the ability of field personnel from the Philippine Department of Social Welfare and Development to introduce a local institution building dimension (i.e. rural development participation and resource mobilization) into their current welfare assistance projects may well make their projects more sustainable. The appropriate policy strategy implicit in the findings of this study is to replace the traditional dole-out system, which only encourages total dependency on the international donors and the central government, with on that encourages self-sufficiency, creativity, and independence. Finally, the findings of the study could be used as a policy reform guide by new cohorts of Philippine public health administrators and policy analysts in their attempt to introduce genuine process decentralization in the form of active community participation as opposed to the more commonly used central government-induced approaches to increasing project sustainability and effectiveness.

Caveats: Inclusion and Dominance Domination of the process can severely affect the extent to which shared ownership in design can be achieved. Dominance can come in many forms, and all varieties have the same stifling effect on individual participation.

Conclusions 141

Typical examples include domination through control or possession of information or expertise which is essential to the problem-solving process. Others are control of the process by interest groups or a vocal minority, or the exclusion of particular alternatives, types of information, or groups. Thus, the lack of participation, unclear roles, dominance of individuals or groups, poor leadership, and wasted time all motivate and stimulate various forms of “dropping out” or active resistance. There is nothing so damaging to a community participation effort as the emergence of a vocal and hostile group of possible participants which has been overlooked. Such groups are quick to challenge the legitimacy of other participants, and often seek to discredit the process. This can have a devastating impact on the effort. This focus is then shifted to questions of legitimacy; choices already made come unstuck; some participants may become defensive; or others simply withdraw from the effort. Finally, where the outside group can be included, the process must backtrack, or at a minimum, bring the new group up to speed. These potential problems emphasize the need for early and comprehensive identification and inclusion of all affected groups and individuals.

Note 'This comprehensive and pragmatic typology of participation is adapted from the classic work of S. Arnstein (1969).

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164 Development sustainability through community participation Shields, R. and Webber, J. (1986). “Hackney lurches local”. Community Development Journal 21, 133-140. Sieddentopf, H. (1989). “Decentralisation for rural development: government approaches and people’s initiatives in Asia and the Pacific”. Planning and Administration 2, 7-11. Sills, P., Marsden, D. and Taylor, T. (1986). “Decentralisation: current trends and issues”. Community Development Journal 21, 84-87. Silverman, J. M. (1990). Public sector decentralization: economic policy reform and sector investment programs. Washington, DC: World Bank. Simon, H. (1946). “Proverbs of administration”. Public Administration Review 6. Simon, H. (1957). Administrative behavior. New York: Macmillan. Slater, D. (1990). “Debating decentralization—a reply to Rondinelli”. Development and Change 21, 501-512. Society for International Development (SID)-Kenya Chapter (1989). “Sustainable development is participatory development”. Development 2/3. Sokolow, A. D. and Honadle, B. W. (1984). “How rural local governments budget: the alternatives to executive preparation”. Public Administration Review 45, 373-383. Solon, F. S., et al. (1984). “The Bulacan nutrition and health study: a summary report of a longitudinal study on infants”. Journal o f Tropical Pediatrics 30, 324-329. Spradley, J. P. (1980). Participant observation. New York: Holt, Rinehart and Winston. Stevens, C. (1987). A.J.D. health projects: comments on *sustainability* issue. Arlington, VA: John Snow, Inc. Stewart, M. J. (1990). “Expanding theoretical conceptualizations of self-help groups”. Social Science and Medicine 31, 1057-1066. Strauss, L. (1953). Natural right and history. Chicago: University of Chicago Press. Sweet, C. F. and Weisel, P. F. (1979). “Process versus blueprint models for designing rural development projects”. In G. Honadle and R. Klauss (eds.), International development administration: implementation analysis for development projects. New York: Praeger Publishers. Tan, C. E. and Balweg, J. A. (1984). “Demographic and contraceptive patterns among women in Northern Mindanao, the Philippines”. Social Biology 31,232-242. Taylor, C. C. (1937). “Sociology on the spot”. Rural Sociology 2, 415-428. Taylor, C. C. (1940). “Social theory and social action”. Rural Sociology 5, 14-31. Taylor, M. with the Newcastle and Sheffield Tenants’ Federations (1986). “For whose benefit? decentralising housing services in two cities”. Community Development Journal 21, 126-132. The Cebu Study Team (1991). “Underlying and proximate determinants of child health: the Cebu longitudinal health and nutrition study”. American Journal o f Epidemiology 133, 185-201.

Bibliography 165 Thomason, J. A. (1988). “Disbursement, decentralization and development: lessons from the first rural health services project in Papua New Guinea”. Public Administration and Development 8, 391-399. Toffler, A. (1971). Future shock. New York: Bantam. Tomita, M., et al. (1982). “The survey of parasitosis (I) in Bay (Philippines)”. Kobe Journal o f Medical Sciences 28, 1-5. Tranquada, R. E. (1973). “Participation of the poverty community in health care planning”. Social Science and Medicine 7, 719-728. Tumwine, J. K. (1989). “Community participation as myth or reality: a personal experience from Zimbabwe”. Health Policy and Planning 4, 157-161. Ugalde, A. (1985). “Ideological dimensions of community participation in Latin American health programs”. Social Science and Medicine 21, 41-53. Union of International Associations (ed.) (1989). Yearbook o f international organizations 1989/90. New York: K.G. Saur München. United Nations (1964). Demographic yearbook. New York: United Nations. United Nations (1965). Demographic yearbook. New York: United Nations. United Nations (1971). Popular participation in development: emerging trends in community development. New York: United Nations Development Programme. United Nations (1977). Demographic yearbook. New York: United Nations. United Nations Development Programme (various years). Human development report. Oxford: Oxford University Press. United States Agency for International Development (1985). Lessons learned from AID program experience in 1984. Washington, DC: Center for Development Information and Evaluation. United States Agency for International Development (1988). Sustainability o f development programs: a compendium o f donor experiences. A.I.D. Program Evaluation Discussion Paper No. 24. Washington, DC: Center for Development Information and Evaluation. UphofF, N. T. (1984). “Participation in development initiatives: fitting projects to people”. In M. Cemea (ed.), Putting people first: sociological variables in rural development projects. New York: Johns Hopkins University Press. UphofF, N. T. (1986). Local institutional development: an analytical sourcebook with cases. Hartford, Connecticut: Kumarian Press. UphofF, N. T. and Cohen, J. M. (1979). Feasibility and application o f rural development participation: a state o f the art paper. New York: Cornell University. Useem, M., Setti, L. and Kanchanabucha, K. (1988). “Predictors of success in a participatory village development project in Thailand”. Public Administration and Development 8, 289-303. Valencia, L. B. (1989). “Social science research on social dimensions of leprosy: where are we going here?”. International Journal o f Leprosy 57. Van Der Geest, S., et al. (1990). “Primary Health Care in a multi-level perspective: towards a research agenda”. Social Science and Medicine 30, 1025-1034.

166 Development sustainability through community participation Van Sant, J. (1987). Benefit sustainability. Washington, DC: Development Alternatives, Inc. Vandenberg, L. and Fear, F. A. (1983). “Participatory research: a comparative analysis of two approaches”. Journal o f Voluntary Action Research 12, 11-28. Varela, A. P. (1984). “Policy issues in integration for rural development: the case of the population/family planning program”. Philippine Journal o f Public Administration 28, 173-202. Vengroff, R. and Johnston, A. (1989). Decentralization and the implementation o f rural development in Senegal: the view from below. New York: E. Mellen Press. Ventura, E. (1986). “Factors affecting participation in blood examination and treatment of filiariasis in Sorsogon, Philippines”. Southeast Asian Journal o f Tropical Medicine and Public Health 17, 464-469. Versoza, C., et al. (1984). “Attitudes towards the rhythm method in the Philippines”. Studies in Family Planning 13, 74-78. Vorathepputipong, T. (1986). Decentralization for rural development in Thailand. Malaysia: National Institute of Development Administration. Walker, T., et al. (1988). SCOPE: A conceptual framework for institutional sustainability. Maryland and Washington, DC: University of Maryland and U.S. Department of Agriculture. Walt, G., et al. (1989). “Community health workers in national programmes: the case of the family welfare educators of Botswana”. Transactions o f the Royal Society o f Tropical Medicine and Hygiene 83(1), 49-55. Walt, G., Perera, M. and Heggenhougen, K. (1989). “Are large-scale volunteer community health worker programmes feasible? the case of Sri Lanka”. Social Science and Medicine 29, 599-608. Waterston, A. (1962a). Planning in Morocco: organization and implementation. Washington, DC: World Bank. Waterston, A. (1962b). Planning in Yugoslavia: organization and implementation. Baltimore, MD: Johns Hopkins Press. Waterston, A. (1963). Planning in Pakistan: organization and implementation. Baltimore, MD: Johns Hopkins Press. Waterston, A. (1969). Development planning: lessons o f experience. Baltimore, MD: Johns Hopkins Press. Weiss, R. (1978). “Alternative approaches in the study of complex situations”. Human Organization 25, 198-206. White, L. (1987). Creating Opportunities for Change: Approaches to Managing Development Programs. Boulder, CO and London: Lynne Rienner Publishers. White, L., Walker, T. and Ingle, M. (1987). Increasing the sustainability o f development assistance efforts: lessons learned and implications for donor agencies. College Park, MD: University of Maryland.

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Appendix 1 Declaration o f Alm a-Ata (1978) The International Conference on Primary Health Care, meeting in Alma-Ata this twelfth day of September in the year Nineteen hundred and seventy-eight, expressing the need for urgent action by all governments, all health and development workers, and the world community to protect and promote the health of all people of the world, hereby makes the following Declaration.

I The Conference strongly affirms that health, which is a state o f complete physical, mental and social well-being, and not merely the absence of disease or infirmity, is a fundamental right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector. II The existing gross inequality in the health status o f people particularly between developed and developing countries as well as within countries is politically, socially and economically unacceptable and is, therefore, o f common concern to all countries. III Economic and social development, based on a New International Economic Order, is of basic Importance to the fullest attainment of health for all and to the reduction of the gap between the health status of the developing and developed countries. The promotion and protection of the health of the people is essential to sustained economic and social development and contributes to a better quality of life and to world peace. 168

Appendix 1 169 IV The people have the right and duty to participate individually and collectively in the planning and implementation of their health care. V Governments have a responsibility for the health of their people which can be fulfilled only by the provision of adequate health and social measures. A main social target of governments, international organizations and the whole world community in the coming decades should be the attainment by all peoples of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life. Primary health care is the key to attaining this target as part of development in the spirit of social justice. VI Primary health care is 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 selfreliance and self-determination. It forms an integral part of both the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process. VII Primary health care: 1. reflects and evolves from the economic conditions and socio-cultural and political characteristics of the country and its communities and is based on the application of the relevant results of social, biomedical and health services research and public health experience;

170 Development sustainability through community participation 2. addresses the main health problems in the community, providing promotive, preventive, curative and rehabilitative services accordingly; 3. includes at least: education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs; 4. involves, in addition to the health sector, all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works, communications and other sectors and demands the coordinated efforts of all those sectors; 5.

requires and promotes maximum community and individual self-reliance and participation in the planning, organization, operation and control of primary health care, making fullest use of local, national and other available resources; and to this end develops through appropriate education the ability of communities to participate;

6.

should be sustained by integrated, functional and mutually-supportive referral systems, leading to the progressive improvement of comprehensive health care for all, and giving priority to those most in need;

7. relies, at local and referral levels, on health workers, including physicians, nurses, midwives, auxiliaries and community workers as applicable, as well as traditional practitioners as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community.

VIII All governments should formulate national policies, strategies and plans of action to launch and sustain primary health care as part of a

Appendix 1 171

comprehensive national health system and in coordination with other sectors. To this end, it will be necessary to exercise political will, to mobilize the country’s resources and to use available external resources rationally. IX All countries should cooperate in a spirit of partnership and service to ensure primary health care for all people since the attainment of health by people in any one country directly concerns and benefits every other country. In this context the joint WHO/UNICEF report on primary health care constitutes a solid basis for the further development and operation of primary health care throughout the world. X An acceptable level of health for all the people of the world by the year 2000 can be attained through a fuller and better use of the world’s resources, a considerable part of which is now spent on armaments and military conflicts. A genuine policy of independence, peace, détente and disarmament could and should release additional resources that could well be devoted to peaceful aims and in particular to the acceleration of social and economic development of which primary health care, as an essential part, should be allotted its proper share. ♦ ♦♦

The International Conference on Primary Health Care calls for urgent and effective national and international action to develop and implement primary health care throughout the world and particularly in developing countries in a spirit of technical cooperation and in keeping with a New International Economic Order. It urges governments, WHO and UNICEF, and other international organizations, as well as multilateral and bilateral agencies, non-governmental organizations, funding agencies, all health workers and the whole world community to support national and international commitment to primary health care and to channel increased technical and financial support to it, particularly in developing countries. The Conference calls on all the aforementioned to collaborate in introducing, developing and maintaining primary health care in accordance with the spirit and content of this Declaration.

Appendix 2

M ALA CA N AN G M anila

Executive Order No. 851 R eorganizing the M inistry o f Health, Integrating the Com ponents o f Health Delivery Into Its Field Operations, and for Other Purposes

Whereas, under the New Republic, national development shall be pursued with renewed dedication and greater determination through a more efficient, effective and economical government; Whereas, the integration of the promotive, preventive, curative and rehabilitative components of health care delivery must be fully accomplished to ensure adequate health services for the entire population; Whereas, there is a need to reorganize the Ministry of Health in order to accomplish this integration; and Whereas, under Presidential Decree No. 1416 as amended, the President is empowered to undertake such organizational and related improvements as may be appropriate in the light of changing circumstances and new developments; Now, therefore, I, Ferdinand E. Marcos, President of the Philippines, by virtue of the powers vested in me by the Constitution and the authority vested in me by Presidential Decree No. 1416 as amended, do hereby order and ordain:

172

Appendix 2 173 Section 1. The Ministry of Health, hereinafter referred to as the Ministry, shall be the ministry having primary responsibility for the formulation, planning, implementation and coordination of policies and programs in the field of health. The primary function of the Ministry is the promotion, protection, and preservation of the health of the people, through efficient, effective, encompassing, equitable, and adequate health services. The functions, authority, and responsibilities of the Ministry shall be within the context of and subject to the constitutional mandate on the formulation of national guidelines and the control of the ministries by the President, the supervision of the ministries by the Prime Minister, and the responsibility to the Batasang Pambansa of the Prime Minister and the Cabinet for the general program of government.

A. Organization of the Ministry Section 2. The authority and responsibility for the exercise of the powers and the discharge of the functions of the Ministry shall be vested in the Minister of Health, hereinafter referred to as the Minister. He shall be assisted by such Deputy Ministers as may be appointed by the President. The Minister is authorized to determine and assign the respective functional areas of responsibility of the Deputy Ministers, should there be more than one: Provided, That such delineation of responsibilities shall cover the substantive functions and operations of the Ministry; and Provided further, That there shall be no Deputy Minister for Administration and that the assignment o f administrative responsibilities to any Deputy Minister shall be in addition to this substantive responsibilities. The Ministry shall be composed of the Ministry proper, staff and line bureaus, special projects, medical centers and special hospitals, and regional offices and their component units. Section 3. There is hereby created a Health Education and Manpower Development Service which shall assume the functions of the Office of Health Education and Personnel Training and those of the Medical Manpower Development Committee, both of which are hereby abolished. The new Service shall also be responsible for providing the necessary staff support in the implementation of the Rural Health Practice Program. It shall absorb

174 Development sustainability through community participation

applicable functions, appropriations, records, equipment, property, and such personnel as may be necessary of the abolished units. Section 4. There is hereby created a Bureau of Food and Drugs which shall assume the functions of the Food and Drug Administration which is hereby abolished. The functions to be assumed by the Bureau shall not include those previous functions of the Narcotics Drugs Division of the Food and Drug Administration which have already been assumed by the Dangerous Drugs Board pursuant to Batas Pambansa Bilang 179. In addition to those functions transferred from the Food and Drug Administration, the Bureau shall have the authority to prescribe general standards and guidelines with respect to the veracity of nutritional and medicinal claims in the advertisement of food, drugs and cosmetics in the various media, to monitor such advertisements, and to call upon erring manufacturer, distributor, or advertiser to desist from such inaccurate or misleading nutritional or medicinal claims in their advertising. Should such manufacturer, distributor, or advertiser refuse or fail to obey the desistance order issued by the Bureau, he shall be subject to the applicable penalties as may be prescribed by law and regulations. Section 5. The Bureau of Quarantine shall continue to perform its present functions, including supervision over rat-proof zones in designated international ports and airports and over medical examination of aliens for immigration purposes. The function of the Ministry regarding supervision of interisland vessels may be exercised by the Ministry through such of its field offices or the Bureau of Quarantine as it may indicate. Section 6. The staff bureaus and special projects enumerated under Section 8 hereunder may, operating through the Minister, directly exercise line functions in the National Capital Region; Provided, that written delegation of authority has been obtained from the Minister; Provided further, that such an arrangement will be permissible only for as long as the regional office of the Ministry for the National Capital Region has not been established. Section 7. The Ministry proper shall be composed of the following units:

Appendix 2 175

(1) (2) (3) (4) (5)

Office of the Minister Planning Service Financial and Management Service Administrative Service Disease Intelligence Center, which is hereby renamed Health Intelligence Service (6) Health Education and Manpower Development Service

Section 8. The Minister shall exercise supervision and control over the following staff bureaus and special projects: (1) Bureau of Dental Health Services (2) Bureau of Food and Drugs (3) Bureau of Health Services (4) Bureau of Medical Services (5) Bureau of Research Laboratories (6) Dermatology Research and Training Project, which is hereby renamed Dermatology Research and Training Service (7) National Family Planning Office, which is hereby renamed Family Planning Service (8) Malaria Eradication Service (9) National Cancer Control Center, which is hereby renamed Cancer Control Center (10) National Nutrition Service, which is hereby renamed Nutrition Service (11) Radiation Health Office, which is hereby renamed Radiological Health Service (12) Schistosomiasis Control and Research Service Section 9. The Minister shall exercise supervision and control over the following line bureau: (1) Bureau of Quarantine Section 10. The Minister shall exercise supervision and control over the following medical centers, hospitals, and research institutes: (1) Jose R. Reyes Memorial Hospital, which is hereby renamed Jose R. Reyes Memorial Medical Center (2) Rizal Medical Center (3) Ospital ng Bagong Lipunan (4) Jose Fabella Memorial Hospital

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(5) National Children’s Hospital (6) National Mental Hospital (7) National Orthopedic Hospital (8) Quirino Memorial General Hospital (9) San Lazaro Hospital (10) Research Institute for Tropical Medicine Medical centers and regional hospitals which are not listed above and which are located outside Metro Manila shall be under the supervision and control of the appropriate Regional Health Office. Section 11. The Minister shall exercise administrative supervision over the following entities: (1) Dangerous Drugs Board (2) Philippine Medical Care Commission (3) Schistosomiasis Control Council Section 12. The following corporation shall be attached to the Ministry for policy and program coordination: (1) Tondo General Hospital and Medical Center, which is hereby renamed Tondo Medical Center.

B. Field Services of the Ministry Section 13. Regional Health Offices. (1) The Ministry shall have such ministry-wide regional offices as may be necessary, under the supervision and control of the Minister, in accordance with Article I Chapter III, Part II of the Integrated Reorganization Plan as amended. Each Regional Health Office shall be headed by a Regional Director assisted by an Assistant Regional Director. The Regional Health Office shall be responsible for the field operations of the Ministry in the region and for providing the region with effective health and medical services, utilizing the Primary Health Care approach which provides that health and medical services shall be responsive to the prioritized needs of the community as expressed by its members, and which mandates community participation in the determination of its own health requirements.

Appendix 2 177

The Regional Health Office shall have supervision and control over the Regional Hospital, over such medical centers as may exist in the region, and over the various provincial health offices in the region. (2) The Regional Hospital shall have as part of its integrated facilities such regional laboratories and regional mental hospitals as may exist in the region, subject to the following provisions. The Regional Hospital shall be headed by a Chief of Regional Hospital, who shall be under the supervision and control of the Regional Director. The Regional Laboratory, formerly directly under the Regional Health Office, shall be transferred to and made part of either the Regional Hospital or the Medical center in the region, whichever is nearer in location, including applicable appropriations, records, equipment, property, and such personnel as may be necessary. The Regional Mental Hospital, formerly directly under the Regional Health Office, shall be transferred to and made part of the Regional Hospital, including applicable appropriations, records, equipment, property, and such personnel as may be necessary. (3) The line functions of the Family Planning Service, the Malaria Eradication Service, the Nutrition Service, and the Schistosomiasis Control and Research Service shall be integrated into the appropriate Regional Health Office, including applicable appropriations, records, equipment, property, and such personnel as may be necessary. Section 14. Provincial Health Offices. (1) The Provincial Health Office and the Provincial Hospital are hereby merged to constitute a new integrated Provincial Health Office. It shall be responsible for the complete integration of the promotive, preventive, curative, and rehabilitative components of health care delivery within the province, as provided by the National Government. It shall absorb the applicable functions, appropriations, records, equipment and property of the merged units. The positions of Provincial Health Officer and Chief of the Provincial Hospital shall be merged into one position, and the staff of the new Office shall be combination of the qualified personnel of the two merged offices. Neither the incumbent provincial health officer nor the incumbent head of the provincial hospital shall have prior right to be appointed or assigned as head of the new

178 Development sustainability through community participation integrated Provincial Health Office. The Provincial Health Office shall under the supervision and control of the Regional Director. The Provincial Health Office shall exercise supervision and control over district hospitals and other field health units of the Ministry in the province, except those placed directly under the Office of the Minister under Section 10 hereof and the regional hospitals and medical centers under Section 13 (1) hereof. The provincial health officers and the assistant provincial health officers shall be appointed by the Minister of Health; Provided That their assignments to particular provinces shall be made only upon consultation with the governor concerned. Their compensation shall be paid out of national funds. (2) The emergency hospitals, which shall henceforth be known as district hospitals, shall exercise supervision and control over all field health units in their respective areas as the first step in the implementation of the integrated concept of health and medical services in the province. The rural health units and specialized field health units, in addition to their present functions, shall serve as the outpatient services of the district hospitals in their respective areas. Barangay health stations shall in turn be considered as extensions of rural health units. Eventually, all personnel of field health units who are permanently assigned in the catchment areas thereof shall be absorbed by the district hospitals. The functions of the Family Planning Service, the Malaria Eradication Service, the Nutrition Service, and the Schistosomiasis Control and Research Service, insofar as they pertain to field operations, shall be integrated into the Provincial Health Office within a period of two years after approval of the reorganization of the Ministry. This integration shall include applicable appropriations, records, equipment, property, and such personnel as may be necessary. Section 15. City Health Offices. The city health officers and the assistant city health officers shall be appointed by the Minister of Health; Provided That their assignments to particular cities shall be made only upon consultation with the city mayor concerned. Their compensation shall be paid out o f national funds. Section 16. Local Government Health Services. The provision by the Ministry of health and medical services shall be without prejudice for any

Appendix 2 179

provincial or city government to establish its own health and medical services; Provided, That the Ministry shall provide the necessary technical supervision in the provision of such health and medical services by the provincial or city government. Section 17. The Minister shall have the authority to delegate such substantive and administrative powers and authorities as may be necessary to the heads of the regional health offices, in addition to such administrative authorities as have been mandated for delegation for all Ministries by the President. The Minister shall also delegate such powers and authorities to the heads of the provincial health offices and those of other subordinate units of the regional health offices as in his judgement would made for a more efficient and effective administration of health and medical services. Section 18. The Minister is authorized to phase out the schools of nursing operated by the Ministry within a period of two years. Section 19. Appointments to supervisory positions in the field health services of the Ministry, which are outside the scope of the Career Executive Service such as provincial and city health officers and assistant provincial and city health officers, shall be made on a general basis. The Minister shall have the authority to indicate the specific assignments of the appointees, such as to a specific geographical area or a specific hospital facility, and to rotate or transfer them as necessary; Provided, That there shall be no diminution of their salaries as a result of such rotation or transfer.

C. Miscellaneous Provisions Section 20. The Minister is hereby authorized to issue such orders, rules and regulations as may be necessary to implement the provisions of this Executive Order; Provided, That approval of the Office of Budget and Management is obtained relative to the new staffing pattern including appropriate salary rates, the organizational structure at divisional and lower levels, and the realignment of existing appropriations. The Minister may appoint qualified personnel to appropriate positions in the reorganized Ministry and those not so appointed are deemed laid off.

180 Development sustainability through community participation Section 21. All those who are laid off under the provision of this Executive Order shall be entitled to all benefits and gratuities provided under existing laws. Section 22. All laws, decrees, orders, proclamations, rules, regulations, or parts thereof, which are inconsistent with any of the provisions of this Executive Order are hereby repealed or modified accordingly. Section 23. Any portion or provision of this Executive Order that may be declared unconstitutional shall not have the effect of nullifying the other provisions thereof; Provided, That such remaining portions can still stand and be given effect in their entirety to accomplish the objectives of this Executive Order. Section 24. This Executive Order shall take effect immediately. Done in the city of Manila, this 2nd day of December, in the year of Our Lord, Nineteen Hundred and Eighty-Two. (Sgd.) President of the Philippines By the President (Sgd.) Juan C. Tuvera Presidential Executive Assistant

Appendix 3

O ffice o f the Philippine President Presidential Com m ission on G overnm ent R eorganization (PC G R )

R ecom m endations for the Reorganization o f the M inistry o f Health (PCGR Book II, 1986)

The health situation of the majority of the Philippines particularly in the rural areas has not improved greatly. Life expectancy (61.8 years) has not increased since the 1970s. Communicable disease are still major killers, infant mortality averages 51 per thousand (probably underreported). Infant and child malnutrition remain unnecessarily high. Limited access to health care services due to a poor physician/population ratio, especially in the rural areas, as well as the high cost of drugs makes medical services inaccessible to most. Adequate medical care is still beyond the reach of 70 per cent of the population, particularly in the rural areas. The fact however that communicable disease remain as major killers in the Philippines means that promotion and prevention of disease is still a major challenge. The fact that medical services are unavailable outside urban areas and that physicians and nurses are reluctant to serve in remote rural areas is still a major obstacle to access health services to all. The promotion of health, a concern both of families and communities, should be systematically pursued by all entities of society to deal with communicable diseases. A concerted effort to mobilize all sectors of society to promote and take preventive health measures needs to be undertaken.

181

182 Development sustainability through community participation

Potable water, environmental sanitation remain issues in many areas. Adequate food distribution relate to adequate nutrition. These are issues that have to be addressed with equal attention as the promotion of health and the establishment of an adequate health care system.

MANDATE The overall mandate and objective of the Ministry of Health shall remain substantially the same as the existing one; which is very clear. It is to formulate, manage, administer, operate and implement policies, programs and activities that assure the delivery of adequate promotive, preventive, curative and rehabilitative health services to the entire Philippine population in an efficient, effective, comprehensive and equitable manner. While the mandate is still relevant, it is felt that the thrust towards decentralization should continue to insure greater access to health care services and primary health care services should be planned and coordinated by the Ministry of Health. Thus as effective network of primary, secondary and tertiary level health care services can be assured the population and appropriate referrals can be made from one level to the other. The main constituency of the Ministry of Health shall be those who are currently unable to access themselves to adequate health services. The main reorganizational strategy of the Ministry is to ensure its accountability for the consolidated and coordinated service delivery of all health and health related services, both of the national and local government and that of the private sector as well. The Ministry of Health will conduct studies towards the gradual privatization of health services currently being rendered by government maintained facilities both at the secondary and tertiary level.

GENERAL RECOMMENDATIONS Functional recommendations As the primary agency of government that will ensure comprehensive health care coverage for all citizens, MOH will reconstitute itself to more

Appendix 3 183

effectively carry this out. It is essential that all health and health related services of both government and private sector be coordinated by MOH. It should encourage private sector participation and its regulatory function should be limited to enforcing adequate standards for medical care. It should at all times be able to monitor whether the health care system adequately covers the populations. In this context the following functions are essential to MOH: 1. It should maintain an up-to-date health intelligence network so that the planning for health services become more responsive to local needs. 2. It should initiate and coordinate all health research and development activities so that these become user-oriented and new knowledge in health care can be quickly utilized by the delivery system. 3. It should continue and build up the tertiary level health care systems in the regions to make specialized services available to rural residents. 4. It should concern itself more actively in setting the standards for occupational health, as well as in the delivery of this health care service. The Ministry of Labor should concern itself mainly with the enforcement of these standards. 5. It should coordinate all primary health care activities of the government and the private sector to ensure that the health care networks at all levels - primary, secondary and tertiary is operating adequately.

Structural 1. The MOH will be reorganized primarily in the Central Office and the decentralization of all services and the structures necessary to access all levels of health care to all which was started in 1983 will be continued. The central office of MOH will be reorganized to have 5 Deputy Ministers accountable for five basic services. These will be (1) Special Operations; Food and Drugs (product evaluation, regulation and

184 Development sustainability through community participation

administration); Quarantine; Production of Vaccines, biologicals and herbals; Laboratories (Research, Testing Laboratories) (2) Management Services Administration, Finance, Internal Audit and Management Systems, Training and Manpower Development; Procurement (3) Public Health - family health, disease control and community health services (4) Facility Management and (5) Metro Manila Operations - There shall be two Assistant Ministers, for Planning and Field Operations. The Regional Health Officer, Provisional and Municipal Health Offices will be maintained as well as the rural health stations. 2. health related.

The attached agencies of MOH shall be those which functions are

a. In this context the Commission on Population can continue its efforts to educate mothers and fathers in responsible parenthood and in their desire to space their children, which in very poor families, are so very necessary, but respecting the right to life of every unborn child, and the right of the father and mother to determine the family size and consider the views of the predominant Catholic populace. The National Nutrition Council can be merged with the remandated Commission on Population into a Population and Nutrition Council to become the arm of the Ministry of Health that will plan, coordinate, and monitor programs related to population and nutrition which are important components of the primary health care program. b. It is also recommended that the four specialized hospitals (Lungsod ng Kabataan, Kidney Center, Lung Center and Heart Center) be given a Special Charter for its independent operational accountability and be mandated to pursue educational and research activities, while giving service (accepting patients) as well, to promote the education of specialized medical services to the regions; the Special Charter should allow medical students from all medical school access to its educational and training courses. The MOH should be represented in these Special Chartered Hospitals. c. The Medicare Commission being essentially a health insurance plan should be privatized to compete against all other private health insurance companies and should not get involved in health service deliveries. d. The entire Metro Manila Health Operations should be transferred to the MOH, to form the core of the National Capital Region Office in the

Appendix 3 185 future. In a similar manner all City Health Offices should be under MOH to ensure standards of service. e. The Philippine Council for Health and Research Development should be remandated to be more responsive to health care needs and should be attached to the Ministry of Health. f. The Minister o f Health should actively participate in setting the standards for Medical Education and should be the Vice Chairman of the Board which can remain attached to the Ministry of Education. g. The Minister of Health is also recommending the formation of a National Council of Health Advisers which shall include the private sector that shall recommend policies on health care and shall serve the Ministry as a feedback mechanism on the status of health care delivery system. It shall also assist long-term planning for a more viable health care system. Non-structural 1. The MOH should initiate the formulation of a National Health Code that will define clearly the standards for the health care delivery system as well as the roles of all sectors in providing health services to the people. This should be accomplished with the participation of all sectors of the society. 2. The mandate of the government to render basic health services to the people should be clearly stated in the new Constitution. 3. MOH should conduct studies on the feasibility of a system for comprehensive medical coverage for all. 4. MOH should encourage the use of generic names for essential drugs. This will effectively lower the price of drugs. Internally as an operating policy on purchasing this can take effect immediately.

Index References from Notes indicated by ‘n’ after page reference analysis 3, 9,14, 18, 20, 24-26, 42, 44-47, 59, 83,87, 111, 114, 119-120, 131, 138-139 analyze 2, 137 Anyanwu, C. 25 Appleby, P. 14 approach 2, 5-6, 9-11, 13-17, 19-20, 23-24, 27, 29-30, 35n-36n, 38, 40, 42, 48-49, 58, 64, 66, 69-73, 76-78, 80-81,83-84, 86-90, 9294, 136-137, 140 Aquino, C. (former Philippine President) 72-73 Argyris, C. 14,23,26 Armor, T. 38 Amstein, S. 134, 141n Asia 1-2, 5, 20, 50, 53, 55-56 Asian Development Bank 54 Askew, I. 37 assessment 24, 89, 104, 109 Australia 28, 55 Azurin, J. 68, 71, 94n

Abdi-Farah, A. 47 academic 2-3,21,24,29-30,33,35, 39, 68, 82-83,86,91, 108, 111, 121 Achen, C. 26 action research 26, 83, 106, 109 action science 26 active participation 22, 82, 100 activity 22, 24, 26, 45, 49, 93, 121, 127, 131 administration 3, 5, 7,11, 13, 18, 20, 38-39, 41-42, 58,61, 66, 74, 95, 103, 109, 120, 126 administrator 12, 21, 30, 33, 36, 4748, 62, 67, 73, 125, 128, 136, 140 advantage 2, 3, 24, 26 affirmative 5-6, 36-37, 50, 95, 132133 Africa 4, 5, 19, 31-32, 34, 44, 50, 53-54, 56-58, 114, 130n agenda 90,102,117 agriculture 3,20,30,41-42,50-53, 55-56, 58, 63,71,85, 107, 123 aid 5, 28, 43, 57, 61, 69, 99, 107,

Bacharach, S. 23 Bagong Silang project 89 Bagong Silangan Nursing Clinic Project 77 Bales, R. 26 Bamberger, M. 2 Bangladesh 54, 56 barangay 55,68, 74-76, 78, 80-81, 85, 88, 97-108, 115-116, 118, 120, 123-129, 13 In Barba, C. 88 Barnard, C. 14

112 Alampay, M. 25 Albano, R. 84 Albay 75 Alfiler, M. 27, 89, 93, 128 Alfonso, F. 139 Alma-Ata 168-171 alternative 11-12, 25, 35n, 50,75, 106 Alutto, J. A. 23 186

Index 187 Barrion, L. 85 basic 28, 32-33, 54, 72 basic human needs 85 Bataan 80 Bautista, M. 23, 69, 84, 93, 126, 130 Bealer, B. 35n Belize 58 Bell mission 62-63 beneficiary 13, 18-19, 22, 24-26, 35, 39, 41, 52, 70, 75-78, 79, 88-91, 94, 133, 137 benefit 2, 7, 17-21, 26, 28-29, 3133, 37, 39, 42, 77, 79-80, 83, 85, 91, 93-94, 133, 139 Bhatnagar, B. 2 BHW (Barangay Health Worker) 124-128 blueprint 22-26, 39, 42, 63, 65 Blumenfeld, S. 44-45 Bolivia 52, 54, 58 Boostrom, E. 44-45 Bossert, T. 29,31-34, 138 Botswana 49 Brazil 58 Brillantes, A. 63, 67 Briscoe, J. 2 Brown, L. D 29 Brownlow, L. 12 Brundtland Conference 28-30, 35n, 38-40, 54 Bryant, C. 13In Budd, R. 25 budget 44, 46, 64, 88, 95n, 105, 123-125 Bulacan 79-82 bureaucracy 10-12, 15, 35n, 62-65, 67,70, 78, 87, 115, 125, 136137 Buzzard, S. 36, 40-42 Canada 7, 78, 83 capacity building 26, 38, 132, 138 Capul, R. 85

Caragay, R. 81-82 Carino, L. 6, 63-64, 67-68 Carney, W. 91 case 1 ,8 ,2 1 ,2 5 ,3 5 ,5 3 ,5 7 ,5 9 , 124-125, 128 case study 40-41, 101, 117, 130, 13 In, 136-137 Cassan, R. 34 Castillo, G. 15,20,26 Cavite 55-56 Cebu 63, 69, 83-84, 86-87 Cebu Study Team 86 centralization 1, 61, 63-65, 95, 140 Chambers, R. 19, 20, 35n, 37, 40, 42 change 9, 14, 23, 25-26, 42-43, 48, 50,71-72,80,94, 97, 111, 113, 120, 129, 135-136 chart 71 Cheema, G. 11 child health 45, 87, 98-99, 123, 126, 128 children 21, 95, 99, 105, 107-108, 118, 124 China 55-56,62,74 citizen 11,134-135 civil servant 21,33 civil service 62 Claquin, P. 37,40,42 classical approach 13 Cohen, J. 1, 17-20, 26, 36n collaboration 8, 14, 22, 25-26, 31, 41, 49-50, 70-71, 74-75, 87-92, 94-95, 106, 110, 129, 133, 137138 Colombia 49, 58-59 communication 3,22,25,41,63, 78, 95n, 134, 139 community 12, 14, 16-18, 24-25, 3235, 51-53, 57, 65, 66-70, 97-141 community development 97 community education 85 community health worker 49, 73, 78, 82,91, 111 community participation 1, 2 ,4 ,6 , 8,

188 Development sustainability through community participation 15-22, 31, 50, 52-62, 70-72, 8184, 94-95, 105, 130-141 community-based health program 68-69, 76 community-based health workers 89 complex 14-15, 85 computer 2-3, 8n, 9, 26, 74 conceptualization 43 conservation 2, 51, 55, 63 constraint 3,6, 71, 78, 88, 92, 101, 124, 131 contextual factor 6, 31, 34, 42-43, 45-46, 55-56, 74, 95 Conway 23, 29 cooperative 20, 33, 44, 77, 90, 98 cost 11,20,32,45-46,50,53,70, 73, 122, 129 Costa Rica 59 culture 13, 27, 51, 63, 96, 107, 116117, 119 Dachler, H. 26 Dahl, R. 13 data mining 2, 8n database 2-3, 5-7, 8n, 36, 43-44, 50, 54, 103, 131 de Ferranti, D. 2 de la Paz, T. 69, 89 De La Salle University 107-113, 116, 123, 129n decentralization 5, 9-14, 31, 34, 52, 54-59, 61, 68, 70, 73-74, 97, 105-106, 115, 117, 136-140 déconcentration 12 definition 5, 9, 15-19, 32, 34-35, 41, 131 degree of interaction 21-22, 79, 81, 83, 87-88, 100, 109, 117, 125 delegation 12,66 Deming, D. 14 Department of Health 8,63-66,6869, 71, 74-76, 78-83, 86-89, 9394, 95n, 130n-131n determinant 6,38-39,41-43,46-48,

57-59, 95, 116, 122, 133, 137 developing countiy 135 development 1-20, 23, 25-36, 38-60, 66, 69, 79, 84, 86, 90, 95-109, 113, 115, 122-123, 135-136, 138-140 development administration 3, 5, 38-39,41-42, 58,61,65-66 development expert 39-40, 46, 63, 106 development literature 5, 9, 15-17, 19-20, 23, 32 devolution 12 diagnosis 26, 72 disability 72, 118 disadvantage 52, 134 discussion 5-6, 9, 22, 35, 41, 61, 7577, 80, 82, 86, 89,94,109, 111, 113, 117, 126-127, 138 disease 33, 51, 54, 56, 58, 67, 7172, 93, 108, 110, 114-118, 121, 123-124, 127-128 Drucker, P. 14 Dunlop, D. 32 ecology 29-30 economic 2-3, 7, 17, 27-31, 36n, 39, 43, 46, 50-52, 54-57, 61-63, 66, 68, 70, 72-73, 76, 84-85, 92-93, 96-97, 109, 116-120, 132 Economic Commission for Latin America 17 economic system 61-62 education 2, 25-26, 45, 50-60, 63, 69, 72, 78, 85, 96, 98, 107, 110, 112, 114, 118, 120-122 effective 11-12, 39, 42,44, 54, 56, 56, 65-66, 73, 75, 78-79, 82, 84, 93, 95, 119, 128, 131-132, 136138 effectiveness 5-6, 15, 31, 35-36, 4243, 46, 48, 51-60, 65, 69, 82, 96 efficient 93 effort 114-115, 122, 127, 129, 131,

Index 189 135, 139, 141 Egypt 39, 57 empowerment 90, 139 Endriga, J. 62 engineering 3, 23, 134 environment 2, 9, 28-30, 36n, 4648,51, 53-59, 72, 77, 98, 108, 110, 118, 131, 139 epidemiology 74 equal 5, 14, 16, 36, 46, 99, 132, 135 equality 61 examination 3, 5, 36n, 41, 81, 95, 112, 118-119 exchange 81, 99, 104 executive order 71, 73-74, 96 expanded programme on immunization (EPI) 99 experience 1, 6, 39, 41, 49-55, 57, 59-60, 61, 66, 74, 77, 86, 91, 101, 114, 119, 126, 129, 131132 experimental 23, 26, 78, 81, 83, 88 extension 51-52, 60, 72, 125 external factor 5, 36, 42, 47, 49-52, 54, 130, 137-138 facilitator 51, 138 factor (see also determinant) 5-6, 31, 34, 36-37, 39, 41-47, 49-60, 68, 74, 76, 79, 81-83, 88, 108, 117, 130, 132, 137-138 failure 16, 25, 87, 94, 122, 128, 132 family planning 33, 44, 53, 57, 72, 76-77, 80, 86-89, 92, 96-105, 124 FAO (Food and Agriculture Organisation) 50 Ferrer, E. 85 field 3, 10-12, 15, 19, 23, 38, 42, 56, 60, 64-65, 74, 100, 103-104, 125, 140 filariasis 81, 115, 131n Filipino 62, 73, 96 finance 127

financial 2, 5, 27, 29-30, 32, 34, 39, 46-49, 51, 55, 57, 58, 61, 68, 75, 79, 83-84, 88, 92, 94, 98-99, 101-102, 104-105, 114, 121, 126, 129, 132-133, 139 financing 31, 33, 41, 43, 46-48, 50, 53, 55, 57, 60, 62, 73, 75-76, 120, 124 Finsterbusch, K. 18-20, 26, 36n, 37, 40, 42 Flavier, J. 69 food 32, 57, 71-72, 85, 99, 107, 110, 128 food aid 57 forecasting 29 forest 36n, 51, 55, 107 Foronda, M. 25 forum 120, 139 Friere, P. 38 funding 2, 32, 39, 44-47, 52, 60, 109, 123-124, 136 fiiture 6, 16,45, 121, 131 Gilson, L. 47-49 global 28-30, 123, 139 Go, S. 23, 76, 98-99, 104, 108n GO-NGO partnership 100 Goldsmith, A. 47 Golembiewski, R. 14 Gonzalez, J. 61, 134 Goodenough, W. 26 government 2, 3, 10-12, 20, 30, 41, 44-45, 47, 49, 51, 54, 56, 62-73, 76-77, 81-83, 85-88, 92-93, 9799, 102, 104-106, 109, 116-122, 124-125, 128-129, 132-140 Gow, D. 29,37,39,42 GSRC (Government Survey and Reorganization Committee) 6263 Guatemala 45, 59 guide 41, 54, 74, 84 Gulick, L. 12 Guthrie, G. 88

190 Development sustainability through community participation Haiti 53,58 Hall, B. 25-26 Hanunuo Mangyan 5, 83-84, 95, 105-116, 123, 129, 132, 134, 139 health 3,6-7,17, 31-33,42-44,47, 50-55, 63-91, 94n, 95-128, 132, 134 health care 2, 6, 21, 29, 31-32, 36n, 43-45, 55, 57-60, 63, 104-113, 115, 119-129, 131-133, 136-139 health care delivery system 5,61 health development 3 Herrin, A. 92-93 Herzberg, F. 14 history 25, 73 HMO (Health Maintenance Organization) 74-75,138 Honadle, G. 26, 29, 31, 34, 36, 3839 Honduras 42, 44, 49 Hongvivatana, T. 37, 40, 42 human development 1,15, 30, 36n, 84-85 human relations school 13-14 human resource 7, 31, 37, 39 Hume 47-48 Ignacio, L. 79 Iloilo 63, 83, 92-93 immunization 21, 32, 52,66, 71-72, 112, 115, 123, 128, 130n implementation 2, 7, 10-12, 16, 1821, 23, 25-26, 29-31, 39, 41, 4446, 49, 51, 54-55, 64-67, 69, 71, 75-78, 81, 83-84, 86-87, 89-93, 94n, 101, 105-106, 109-113, 116-119, 121, 123-128, 131132, 136, 138 improvement 84, 86 India 42, 52, 55-56,62 indigenous 54, 57 Indonesia 38-39, 52-53,114,139

infant mortality 123 information 2-3, 6-7, 8n, 23, 47-48, 51-59, 72-73, 75, 78-77, 82, 86, 88-89, 91-93, 94n, 103, 106, 116-118, 120, 126-127, 129n, 130n, 131, 134, 140 infrastructure 20, 32, 36n, 41,48, 53, 89-90, 104, 120, 128, 140 initiative 26, 73 input 22, 35n, 40, 42, 51, 82-83, 87, 91, 117, 134 institution 7, 20, 28, 31, 41, 46, 55, 58, 98, 113, 137, 140 institutional development 41 instrument 7, 13-14, 23, 77, 86-87, 90-91, 105 Integrated Reorganization Plan 67, 71 integration 25, 37, 46, 48-49, 58, 129 internal factor 56-57, 132 international 1-2, 13, 27, 30-31, 36n, 38, 45, 53-54, 70, 100, 115, 138 International Bank for Reconstruction and Development (see also World Bank) 2, 5, 28,61, 97, 122 international organization 5, 24, 28, 33, 36n, 61, 79, 97, 139 intervention 38, 53, 55, 82, 87, 89, 109 involvement 1, 7, 12, 14, 17, 19, 2223, 25-26, 28, 30-31, 34, 41, 52, 59, 70, 73-74, 76-77, 84-85, 8891,93-94, 106, 110, 113, 118, 121, 127, 131-134, 137-138 issue 22, 25, 27-30, 35n, 49, 70, 82, 94n, 125 Japan 62, 114 Katiwala 69, 88-89 Kean, J. 36,40,42

Index 191 Khan, A. 37,40 Korten, D. 22, 26, 36, 38-39, 42 Laguna 56,63, 75, 82-83,138 Lamberte, E. 15 language 109, 111 Lara, J. 78 Lariosa, T. 77-78 Latapi, P. 24-25, 27 Latin America 3-4, 17, 50, 53-54, 57-59 laundry list 16-19 law 62-63, 67, 73 learning process 22-26, 39, 42, 77, 85, 121 Legaspi 75 lesson 21, 26, 38, 41, 76, 131, 139 Levine, R. 47-49 Leyte 84 Lieberson, J. 36-37, 40, 42 Likert, R. 14 Linder, W. 30 link 1, 85, 128 linkage 15,20-21,33,42,72,77-78, 87, 104, 120, 129, 137-139 local 2, 6-7, 9-14, 17-21, 26, 32, 3842, 48-49, 51-54, 56-59, 61, 63, 66, 73-77, 81-82, 85-87, 91-93, 97, 99, 101-105, 113, 120-121, 127, 129, 132, 134-138, 140 local government 2, 10, 73, 76-77, 82, 93, 97, 138 local institution 14,41,140 local resource 14, 17,48, 51-53, 56, 59, 85, 91, 101, 104, 120, 127, 132, 136-137 logical positivism 13 logistic 48, 72, 101, 103-104, 121, 124-125 long-term 7, 28, 39, 70, 79-80, 85, 91, 131, 136 longitudinal 86 maintenance 30, 45, 54, 74, 77, 113, 132

MAKAPAWA 85, 90 malaria 32, 44, 56, 66, 70, 78, 108, 112, 122, 126-127 manager 128 Manila 63-66, 74, 78, 82, 88, 98, 100, 104, 115-119, 122-123, 128, 130n Marcos, F. (former Philippine President) 66-67, 71, 96, 122 Maslow, A. 14 Matabungkay Popcorn project 6, 75, 95-105, 132-133 maternal 33, 46, 76, 86, 95, 98-99, 111, 122, 126-127 Mayfield, J. 22, 26, 134 Mayo, E. 13 Mburu, F. 37, 40 McCall, G. 26 McGregor, D. 14 means and ends 15 medicine 7, 43, 57-58,64, 68-69, 81-82, 90, 98, 103, 108, 111, 113, 121-122 meeting 6-7, 16, 22, 27, 75, 77, 8283, 85, 88-89, 92-93, 96, 99, 101-102, 104, 110-112, 118120, 125-126, 134, 138 mental 32,50,66,72,79 Merriam, L. 12 Merton, R. 13 method 24-25, 80 methodology 22-23, 25, 42, 78, 84, 86, 89, 92, 118-119 Mexico 54, 59 Middle East 62 military 62, 79 Mindanao 6-7, 63, 74, 85, 88, 93 Mindoro 63, 83, 92, 106-107, 117, 139 Ministry of Health 55-56,71-72, 126 miracle 1, 60 Misra, R. 65 Mock, N. 32,37,40,42

192 Development sustainability through community participation model 1, 13, 22, 63, 71, 73, 106,

122 Moens, F. 37, 40 monitoring and evaluation 20, 103, 128, 139 Morss, E. 29, 36, 39 Moser, C. 15-16 motivation 14, 19 Mouton, J. 14 movement 9, 17, 69, 89, 98, 114 Myers, D. 65 national government 10,31,45,98, 105, 109, 116, 118, 122, 124, 136, 138 natural resource 28-29, 36n, 57,63, 71 NEDA (National Economic Development Authority) 7, 94n, 96-97 negative 5, 36, 43, 45, 50, 79, 94, 114, 131, 133, 137 Nepal 39,42,55 network 2, 89 NGO (nongovernmental organizations) 2,6-7, 11-12, 15, 20-21,33, 43,51,53-54, 56, 69, 73-76, 78, 83-85, 90, 98100, 103-104, 106-108 Nordlinger, E. 39 Nueva Ecija 6, 76-77, 80, 93, 95, 122-123,125-129,130n, 132133, 139 nurse 36, 64,68, 79, 90, 93, 111113, 126 nutrition 33, 44-45, 50,52, 55,66, 72, 76, 82, 86-88, 91, 94n, 108112, 122-123, 127-128 observation 13, 24, 93, 99, 118, 130n OECD (Organisation for Economic Co-operation and Development) 3, 26-28, 70, 94n

Okamura, J. 25, 83-84, 90, 107, 110, 112, 129n operation 5, 9, 15-17, 19-20, 27, 34, 35n, 40-41, 45-46, 51, 64-65, 75, 99, 110, 112 organization 14-15, 18-20, 24-25, 32, 35n, 38-40, 42, 44, 48, 55, 58-59, 72, 76, 78-79, 83-84, 96, 98, 100, 105, 109, 113, 115 Osteria, T. 83-84, 90, 106-110, 113, 129n, 139 Ostrom, E. 29 Ouchi, W. 14 outcome 1, 7, 9, 24, 31-34, 48, 82, 84, 113, 133, 135 output 2-3, 7, 9, 31-32, 34, 35n, 44, 81,84, 113 Pacific 74 Page, J. 1 Painpanga 75, 79 panacea 2, 5, 122 paradigm 13, 23, 25, 35n participant observer 26 participatory action research 83, 106, 108-109 participatory development 2, 14, 89, 138 partner 51, 55, 80, 98-100 passive 18, 21, 22, 34, 76, 79-83, 87, 93, 116-117, 124, 128 Paul, S. 18-19, 37,40-41, 59 peasant 89 performance 1, 117, 119 perspective 5-6, 14, 16-17, 26, 28, 30, 36, 42, 71, 81, 95 Philippines 5-7, 39, 52, 56, 61-63, 66-67, 69-71, 74, 82-83, 85, 89, 92 plan 19, 22, 63-67, 73, 77, 89, 92, 106, 110, 118, 120, 125, 134135 policy 3, 6, 15, 18, 21-24, 38, 41-42, 49, 54, 60, 63, 67, 73, 75, 79,

Index 193 81-83, 88-89,91,93, 97, 116, 118, 129, 123, 125-127, 131, 134-135, 138-140 politics 54, 66 Popcorn (National Commission on Population) 95-102, 116, 123, 129n, 132-133, 137-139 population 6, 28, 41, 50, 52, 56, 58, 64, 66, 68, 74-75, 91, 95-104, 115-117, 121-123, 129 positive 37, 40, 46, 50, 59, 94-95, 105 poverty 28, 51, 121 practice 2, 13, 25, 29-30, 38-39, 49, 53, 56-58, 64, 67-69, 71, 82, 86, 92, 105, 107, 109, 111-112, 120123, 131-132, 139 practitioner 2, 5, 9, 23, 30, 34, 36n, 65, 72, 76, 123, 132, 139 presidential decree 67, 94n, 96 primary health care 6,41, 45, 50, 52, 57-59, 70-74, 76-77, 81-83, 85-86, 88, 90, 93, 111, 115, 120-129, 132-133, 138-139 process 2, 7, 10, 12-18, 22-27, 31, 34, 37-39, 41-42, 47, 53-57, 65, 70, 73-74, 77, 85, 89, 92-93, 97, 100-101, 106, 110, 115, 120, 125, 133, 135 program 1, 6, 12, 17, 19, 30, 41, 45, 50-51, 53-55, 68-70, 72-73, 76, 80, 83-86, 89, 94-100, 104, 107, 110, 115, 121, 125, 127, 131, 135 project 1-2, 4-9, 12-13, 15-16, 18, 20-27, 29-34, 35n, 41-60, 65-66, 69, 74-94, 97-129, 131-140 proponent 7, 22, 25-26, 34, 41, 70, 75-78, 80-81, 84-85, 87-90, 93, 102, 116, 119-120, 126-128, 133, 137 public administration 3, 7, 63, 65 quality 2, 6, 14, 16, 36n, 49, 66, 81

reform 12-13, 62-65, 67, 69, 73, 97, 140 region 2, 7, 10-12, 20-21, 33, 50, 52, 55-56, 58-59, 63, 67, 74, 81, 83, 88-89, 98, 102, 114-116, 119 reorganization 27, 35n, 62-64, 67, 71, 73, 94n, 139 requirement 68-69, 134 research 1-3,6-7, 19, 21,23-27,2933, 38,40, 49, 55-56, 63, 65, 75, 78, 82-84, 89, 91-92, 98, 105106, 108-111, 115-119, 129n, 136 resource 3, 12, 14, 28, 38, 48-49, 51-56, 59, 62, 65, 67, 71, 75-77, 88-89, 91, 93, 99-101, 103-104, 116, 120-128, 132, 136-137, 140 review 5, 15, 18-19, 31, 36n, 42, 47, 49, 55,67, 97 Rice, J. 26,37,40 Rizal 76 Rondinelli, D. 10-12, 14, 42 sanitation 21, 25, 50, 53, 57-58, 67, 69, 72, 98, 105, 108-109, 112, 114, 117, 119, 126-128 self-help 42, 54 short-term 7, 109 Simon, H. 13-14 skeptic 1, 43, 46, 50, 59, 132-133, 137 society 97, 133 sociology 3, 14, 24-25, 29 Sorsogon 81 Southeast Asia 55, 74, 129n Sri Lanka 49, 54-56 stakeholder 2, 34, 38, 41, 74, 83, 88, 102, 138 strategy 27, 30, 32, 38, 42, 72, 122, 140 survey 14, 23-24, 62, 73, 78-80, 84, 86, 88, 91-92, 100, 102-103, 108-110, 114-115, 117 sustainability 1-2,4-9, 14, 18, 20,

194 Development sustainability through community participation 23-27, 30-34, 38-47, 49-50, 70, 74-75, 79-80, 82, 87, 89-90, 9495, 101, 103-106, 109, 113, 124, 129, 131-133, 136-140 sustainable development 15, 27-30, 39-41, 44, 49, 54, 138 sustained 7, 9, 32-34, 37, 39, 41, 44, 75, 77-83, 85-89, 91-94, 105, 120, 123, 128, 132, 136-138 technical assistance 31-32, 34, 45 technology 3, 38-40, 46, 49, 51-59, 71, 79, 121 Thailand 41-42, 55-56 theory 13,30,39,58,63 traditional 19, 30, 38, 53, 56-57, 61, 64, 72, 77-78, 81-82, 99-100, 107, 111, 121, 123, 134 training 13, 20, 32, 40, 44-45, 47, 51, 68, 72-73, 77, 81-82, 84, 8991, 97-98, 102-103, 107, 110113, 115, 121, 124-126 treatment 71-72,78, 111-112, 116, 118, 127 UN (United Nations) 53 UNESCO (United Nations Educational, Scientific, and Cultural Organization) 50, 54

UNICEF (United Nations Children’s Fund) 56, 87, 91, 122 Uphoff, N. 1, 17-21, 26, 35n, 36, 40-41 Urwick, L. 12 USAID (United States Agency for International Development) 3, 75, 86, 98 Van Sant, J. 28, 31, 34, 36-37, 39, 40 Van Wicklin, W. 18-20, 35n, 40, 42 Varela, A. P. 82 village 14, 16, 21, 25-26, 32, 39, 45, 52, 56-57, 64-69, 71, 73, 78-82, 84-88, 90, 95, 97, 99-106, 113, 115-116, 118, 122-126, 132, 135-139 voluntary 12, 17-18, 20, 105 water supply 44, 50, 53, 55, 57, 109 WHO (World Health Organization) 5, 18, 53, 61, 67, 70, 79, 87, 92, 115, 122 women 21, 54, 89, 108, 112 workshop 2, 55, 111, 119 World Bank 1-3, 18, 28, 41, 49-50, 68, 115