LOCALIZING DEVELOPMENT: DOES PARTICIPATION WORK?
Community engagement in the provision of health care services.
Working with chiefs, village elders, and community volunteers, community-based nurses in Ghana helped develop social insurance mechanisms that allowed formal care to substitute for traditional care.
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A number of randomized control trials have attempted to assess the effectiveness of demand-side interventions in primary health care. A randomized pilot study of Ghana’s Community Health and Family Planning Project (Navrongo) casts some light on the added benefits of engaging community volunteers in the provision of health services (Binka and others 2007). One arm of the intervention tested the impact of adding community-based, volunteer-provided health services to the basic set of clinical services, along with revolving funds and user fees to ensure organizational sustainability. Trained supervisors from the community recruited community health volunteers, organized community supervision of their work, and managed essential health resources. User fees and revolving accounts sustained this work. A second arm deployed trained nurses to villages as “community health officers.” A third arm engaged the community in ensuring that the trained nurses would be available. A fourth arm was held as the control. In the third arm, community members helped construct housing for nurses using volunteer labor, ensuring that nurses could reside in the village. They also provided other types of community assistance and supported services provided by resident nurses. The findings suggest that over an eight-year period, posting nurses to community locations reduced childhood mortality rates substantially relative to control areas. In contrast, volunteer services had no impact on child survival. However, where volunteers worked alongside trained nurses, outcomes were superior to the first two interventions. Working in concert with chiefs, village elders, and community volunteers, community-based nurses helped develop various types of social insurance mechanisms, such as deferred payment. These mechanisms allowed formal care to substitute for traditional care, reducing the delay in health seeking that tends to precipitate childhood mortality (see Nyonator and others 2005 for a detailed discussion). The authors interpret these results as reflecting the limited ability of volunteers alone to change entrenched behaviors like seeking traditional healers. Linnemayr and Alderman (2011) evaluate an intervention in Senegal that focused on the provision of nutrition-related information to mothers of young children through a community-based mechanism. The nutrition intervention was undertaken as a pilot program within the Programme de Renforcement de la Nutrition, which included cooking workshops and a monthly community-level meeting on nutritional