Chasing the dragon: developing indicators for the assessment of community participation in health programmes

Community participation was identified as one of the key components of Primary Health Care as articulated in the Alma Ata declaration of 1978 and is enjoying a renewal of interest in both low and high income countries. There remains, however, an on-going challenge in how to assess its role in achieving health improvements. This is largely due to the multiplicity of definitions of community participation, which has made it difficult to evaluate its impact on desired programme outcomes, such as uptake and sustainability, as well as broader health improvements. This paper addresses this challenge by first defining a continuum of community participation that captures its many forms, and then incorporates this into an evaluation framework that enables an analysis of the process of participation and links this with health and programme outcomes. The continuum of participation and framework is based upon the spidergram of Rifkin, Muller, and Bichmann (1988), but modified in the light of the growing literature on community participation and also in relation to our original requirements to evaluate the role of community participation in nutrition-related child survival programmes. A case-study is presented to provide a worked example of the evaluation framework and its utility in the evaluation of community participation. While this is a literature-based and retrospective analysis, it demonstrates how the evaluation tool enables a nuanced analysis of the different ways in which communities can participate in the delivery of health-related interventions. It could be used prospectively by those involved in programme design and implementation to further our understanding of community participation and its relationship with health outcomes, as well as key programme outcomes, such as sustainability