Community participation in primary health care projects of the Muldersdrift Health and Development Programme

Curationis 30(2): 36-47 After numerous teething problems (1974-1994), the Department o f Nursing Education o f WITS University took responsibility for the Muldersdrift Health and Development Programme (MHDP). The nursing science students explored and implemented an empowerment approach to community participation. The students worked with MHDP health workers to improve health through community participation, in combination with primary health care (PHC) activities and the involvement o f a variety o f community groups. As the PHC projects evolved overtime, the need arose to evaluate the level o f community participation and how much community ownership was present over decision-making and resources. This led to the question “What was the level o f community participation in PHC projects o f the MHDP?” Based on the question the following objectives were set, i.e. i) to evaluate the community participation in PHC initiatives; ii) to provide the project partners with motivational affirmation on the level o f community participation criteria thus far achieved; iii) to indicate to participants the mechanisms that should still be implemented if they wanted to advance to higher levels o f community participation; iv) to evaluate the M HDP’s implementation o f a people-centred approach to community participation in PHC; and v) the evaluation of the level o f community participation in PHC projects in the MHDP. An evaluative, descriptive, contextual and quantitative research design was used. Ethical standards were adhered to throughout the study. The MHDP had a study population o f twentythree (N=23) PHC projects. A purposive sample o f seven PHC initiatives was chosen according to specific selection criteria and evaluated according to the “Criteria to evaluate community participation in PHC projects” instrument (a quantitative tool). Structured group interviews were done with PHC projects’ executive committee members. The Joint Management Committee’s data was collected through mailed self­ administered questionnaires. Validity and reliability were ensured according to strict criteria. Thereafter results were analysed and plotted on a radiating arm continuum. The following factors had component scores: organization, leadership, resources, management; needs and skills. A spider graph was produced after each factor’s Correspondence address: continuum was connected in a spoke figuration that brought them together at the Prof Hester Klopper base where participation was at its most narrow. The results are presented and a graph Private Bag X 6001 an(j discussion is provided on each o f the PHC projects. School o f Nursing Science North-West University (Potchefstroom researc[1 resuits indicated that although community participation was broadened, there was minimal success in forcing a shift in power over decision-making and resources. This demonstrated that power over planning and resources should remain in the hands o f the partners if community participation was to remain progressive and sustained. Results furtherm ore indicated that the people-centred approach to community participation enabled participants to broaden community participation. 36 Curationis June 2007 Campus) Potchefstroom, 2520 Tel: (018) 299-1829/1830 Fax: (018)299 1827 E-mail: hester.klopper@nwu.ac.za With regard to the Joint Management Committee’s evaluation o f community partic ipa tion , it was concluded that pow er over d ec is io n -m ak in g and reso u rces rem ain ed w ith h ea lth p ro fe ss io n a ls ra th e r than w ith the community, and that a people-centred approach had not been adopted. Background to the problem The University o f the Witwatersrand’s (W IT S ) M u ld e rsd rif t H ealth and Development Programme (MHDP) was initiated in 1974 by a group o f concerned medical students who responded to the health needs o f a deprived community, living in a peri-urban area on the north­ western outskirts o f Johannesburg, called Muldersdrift. Unfortunately the student driven programme faltered in 1996 due to lack o f donor funding and commitment. W hile alternative arrangem ents were being investigated, the Department o f N u rsin g E d u ca tio n took over the administration o f the programme from 1995 to 1999. A p a rtn e rsh ip w as n e g o tia ted b e tw een the G au teng D epartm ent o f H ea lth ’s W est Rand Regional Office (WRRO), the University o f the W itwatersrand (WITS) and the M uldersdrift Community through the Muldersdrift Clinic Committee (MCC). A Joint Management Committee (JMC), with four representatives each from these th ree p a rtn e rs , w as fo rm ed . T his provided an ideal opportunity for an evaluation o f the participation o f the community and specifically the MHDP. Rifkin, Muller and Bichmann (1988:933) clarified the community participation process in the context o f Primary Health C are (P H C ), d e fin ed the co n cep t ‘community’ and also hinted at the power sh ifts (em pow erm ent) requ ired for development. They stated: “Community participation is a social process whereby specific groups with shared needs living in a defined geographic area actively pursue identification o f their needs, take decisions and establish mechanisms to meet these needs. In the context o f PHC, this process is one which focuses on the ability o f these groups to improve their health care and by exercising effective decisions to force the shift in resources with a view to achieving equity.” Rifkin (1981:377-386) traced the power shifts that occur with the involvement of laym en in the sp e c ia lise d f ie ld o f medicine and identified four approaches to com m unity participation in PHC. Rifkin and Cassels (1990:39) summarised the community’s role in each o f these four approaches to community participation as; com pliance in the public health approach; contribution in the health planning approach; control in the selfcare approach, and lastly collaboration with eventual control o f activities and resources by the com m unity in the community development approach. One o f R ifkin’s (1981:377-386) identified ap p ro ach es i.e . the com m unity development approach evolved into the radical participatory approach, which g a in ed p ro m in en ce and fu rth e r developed into even more variants, one o f which is the empowerment or ‘peoplec en tred a p p ro a c h ’. The M H D P ’s Constitution was revised and Clause 3 stated that the ‘people-centred approach’ to development was chosen to guide the programme partners (University o f the Witwatersrand, 1984:2). The history o f the MHDP indicates that the m edical students w ere not very successful in implemention o f a ‘peoplecentred approach.’ That the medical students debated Rifkin’s (1981) various approaches to community participation in PHC can be id e n tif ie d in the immunisation drives and the pit toilet building projects in 1988 and 1989 (public health approach). The health planning approach is identified in the employment and training o f community members as family planning motivators, community developm ent officers and community health workers (CHW s). The health planning approach is also identified in the dec is io n -m ak in g p rocess. The m edical s tuden ts had in itia ted and elected the Muldersdrift Clinic Health Committee through which they sought co m m u n ity ad v ice and tau g h t the com m unity p a rtic ip an ts , th rough a dialogue, but ultimately they retained the power over decision-making. As Gaede, (1994:49) reports: “In 1989, a number o f projects w ith partic ipation from the com m unity m em bers, were initiated. A ttem pts were made to run creches, parents meetings, women’s groups and income generating groups. Food gardens and first aid training were tried. But none o f the projects lasted longer than 6 to 8 months. The majority failed because the control and maintenance o f the projects was entirely dependent on the students.” It w asn ’t un til the nursing science 37 Curationis June 2007 students took over the MHDP at the end o f 1995 that the ‘people-centred’ or empowerment approach to community participation was fully explored and implemented in 1996. In this approach the root causes o f health problems are seen as being mainly political as the need ‘to empower’ people acknowledges that th e ir low s ta tu s has re su lted from c o n tin u ed o p p re ss io n by so c ie ty (Wallerstein, 1992inMokwena, 1997:67). Sw anepoel (1 9 9 7 :7 ) s ta ted th a t empowerment means the acquisition of power and the ability to give it effect and it manifests in groups o f people working together. Community participation is seen as a way o f ensuring equity with the poo rest o f the poor hav ing the d em o cra tic r ig h t to p a r tic ip a te in decisions affecting his/her development [health] (Gran, 1983:2; also compare Barker, 2003:5). The people-centred/ empowerment approach to community participation is described in K orten’s (1990:67) definition o f development as; “ ... a process by which the members o f a society increase the ir po ten tia l and institutional capacities to mobilise and m anage re so u rces to p ro d u ce su s ta in a b le and ju s t ly d is tr ib u te d improvements in their quality o f life [or th e ir h ea lth in the PHC con tex t] consistent with their own aspirations” . T h is d e fin itio n im p lies th a t the community should have the power and that this power be directed to ensuring an e q u itab le sh are o f the h ea lth resources. Within this approach the MHDP health care providers had to change from the ‘top-down’ approach to decision-making, w here a ch an g e ag en t s tim u la ted community participation, to a ‘bottomu p ’ approach w here the com m unity acq u ired the pow er and d rove the planning process. The MHDP with the involvem ent o f the nursing science students became what Korten (1990:498) called an adaptive organisation, which he described as organisations “ . . .with a well-developed capacity for responsive and a

With regard to the Joint M anagem ent C om m ittee's evaluation o f community p a rtic ip a tio n , it w as co n clu d ed th at p o w e r o v e r d e c is io n -m a k in g and re so u rc e s re m a in e d w ith h e a lth p ro fe s s io n a ls r a th e r th a n w ith th e community, and that a people-centred approach had not been adopted.

Background to the problem
The University o f the W itwatersrand's (W IT S ) M u ld e rs d rift H e a lth and Development Programme (M HDP) was initiated in 1974 by a group o f concerned medical students who responded to the health needs o f a deprived community, living in a peri-urban area on the north western outskirts o f Johannesburg, called Muldersdrift.Unfortunately the student driven programme faltered in 1996 due to lack o f donor funding and commitment.W hile alternative arrangem ents w ere being investigated, the Departm ent o f N u rs in g E d u c a tio n to o k o v e r th e administration o f the programme from 1995 to 1999.A p a rtn e rs h ip w as n e g o tia te d b e tw e e n th e G a u te n g D ep a rtm e n t o f H e a lth 's W est R and Regional Office (WRRO), the University o f the W itw atersrand (W ITS) and the M uldersdrift C om m unity through the Muldersdrift Clinic Committee (MCC).A Joint M anagem ent Com m ittee (JM C), with four representatives each from these th re e p a rtn e rs , w as fo rm e d .T h is provided an ideal opportunity for an evaluation o f the participation o f the community and specifically the MHDP.
Rifkin, Muller and Bichmann (1988:933) clarified the com m unity participation process in the context o f Primary Health C are (P H C ), d e fin e d th e c o n c e p t 'community' and also hinted at the power sh ifts (e m p o w e rm e n t) re q u ire d for development.They stated: "Community participation is a social process whereby specific groups with shared needs living in a defined geographic area actively pursue identification o f their needs, take decisions and establish m echanism s to meet these needs.In the context o f PHC, this process is one which focuses on the ability o f these groups to improve their health care and by exercising effective decisions to force the shift in resources with a view to achieving equity."Rifkin (1981:377-386) traced the power shifts that occur with the involvement o f la y m e n in th e s p e c ia lis e d fie ld o f medicine and identified four approaches to com m unity particip atio n in PHC.Rifkin and Cassels (1990:39) summarised the community's role in each o f these four approaches to community participation as; co m p lian ce in the p u blic health approach; co n trib u tio n in the health planning approach; control in the selfcare approach, and lastly collaboration with eventual control o f activities and re so u rc e s by the co m m u n ity in the community development approach.One o f R ifkin 's (1981:377-386) identified a p p ro a c h e s i.e. th e c o m m u n ity development approach evolved into the radical participatory approach, which g a in e d p ro m in e n c e an d fu rth e r developed into even more variants, one o f which is the empowerment or 'peoplec e n tre d a p p r o a c h '.T he M H D P 's Constitution was revised and Clause 3 stated that the 'people-centred approach' to development was chosen to guide the programme partners (University o f the Witwatersrand, 1984:2).
The history o f the MHDP indicates that the m edical stu d en ts w ere not very successful in implemention o f a 'peoplecentred approach.'That the m edical students debated R ifkin's (1981) various approaches to community participation in PH C can be id e n tifie d in the im m unisation drives and the pit toilet building projects in 1988 and 1989 (public health approach).The health planning approach is identified in the employment and training o f community members as family planning motivators, community developm ent officers and com m unity health w orkers (CHW s).The health planning approach is also identified in th e d e c isio n -m a k in g p ro c e ss.T he m e d ic a l stu d e n ts h ad in itia te d and elected the M uldersdrift Clinic Health Committee through which they sought c o m m u n ity a d v ic e an d ta u g h t the c o m m u n ity p a rtic ip a n ts , th ro u g h a dialogue, but ultimately they retained the power over decision-making.As Gaede, (1994:49) reports: "In 1989, a num ber o f p ro jects w ith p a rticip a tio n from the com m unity m em bers, w ere initiated.A ttem pts w ere m ade to run creches, parents meetings, w om en's groups and income generating groups.students took over the M HDP at the end o f 1995 that the 'p e o p le-ce n tred ' or empowerment approach to community p articipation w as fully explored and implemented in 1996.In this approach the root causes o f health problems are seen as being mainly political as the need 'to em pow er' people acknowledges that th e ir low s ta tu s has re s u lte d from c o n tin u e d o p p re s s io n by so c ie ty (Wallerstein, 1992inMokwena, 1997:67).S w a n e p o e l (1 9 9 7 :7 ) s ta te d th a t empowerment means the acquisition o f power and the ability to give it effect and it manifests in groups o f people working together.Com m unity participation is seen as a way o f ensuring equity with the p o o re st o f the p o o r h a v in g the d e m o c ra tic rig h t to p a rtic ip a te in decisions affecting his/her development [health] (G ran, 1983:2;also com pare Barker, 2003:5).The people-centred/ empowerment approach to community participation is described in K orten 's (1990:67)  T h is d e fin itio n im p lie s th a t the community should have the power and that this power be directed to ensuring an e q u ita b le sh a re o f th e h e a lth resources.
Within this approach the M HDP health care providers had to change from the 'top-down' approach to decision-making, w h e re a c h a n g e a g e n t s tim u la te d community participation, to a 'bottomu p ' app ro ach w here the com m unity a c q u ire d th e p o w e r an d d ro v e the planning process.The MHDP with the in v o lv e m en t o f the n u rsin g scien ce students became what Korten (1990:498) called an adaptive organisation, which he described as organisations " . ..with a w ell-developed capacity for responsive an d a n tic ip a to ry a d a p ta tio norganisations that: (sic) (a) embrace error; (b) plan with the people; and (c) link knowledge building with action."The M H D P health care pro v id ers had to change their role to that o f an enabling partner in the community participation p ro c e s s .
T h e in te n s ity o f th is enablem ent required adaptation to suit each PHC project's level o f community participation.The MHDP health workers agreed with Rifkin, et al, (1988)  As the PHC projects evolved over time, evaluation o f the level o f com m unity p a r tic ip a tio n a c h ie v e d , by th e participants in each PHC project, became n ec essa ry to g u id e th e in te n sity o f enablem ent required for each project.Rifkin, et al, (1988:931 -940) recognised the need to exam ine the process rather th a n th e im p a c t o f c o m m u n ity participation and put forward a framework an d m e th o d o lo g y , fo r a s s e s s in g community participation, which would be applicable to any health care programme.T h e fa c to rs th e y c o n s id e re d m o st appropriate, as indicators o f community participation, w ere needs assessm ent, le a d e rs h ip , o r g a n is a tio n , re s o u rc e mobilisation, managem ent and focus on the poor.They did not include the last factor, as it was difficult to convert into an indicator.For each o f the other factors a continuum was developed with wide participation at the one end and narrow participation at the other.Rifkin, et al, (1988:937)  Chetty and Owen (1994:1-12) analysed these ranking criteria and applied them theoretically to a number o f PHC projects an d fo u n d th e c r ite r ia to o b ro a d , subjective, conflicting and neglectful o f important details relating to the process o f participation, which led to difficulties in interpretation.T hey took up the challenge to expand Rifkin 's, et al, (1988) w ork to develop criteria, for evaluation, w hich could be adapted to local South African conditions.They agreed with Rifkin, et al, (1988) on the dual value o f the indicators.

Research aim and objectives
The aim o f the research was to measure and describe the level o f com m unity p articipation in PH C pro jects o f the M uldersdrift Health and D evelopm ent Programme.Based on the overall aim o f the study the research objectives were: 1.
To evaluate community participation in the following PHC initiatives in the M uldersdrift Health and Development Programme: • The Joint M anagement Committee (JMC).

•
The M uldersdrift Home Trust Foundation's 'Our Hope (Thembaletu) in Diamond Park Housing Project'. • The Rietfontein Village Association's 'Water Project'.

•
The Ladies Incom e-generating 'Sewing and Crochet Project'.
Each PHC initiative's level o f •community participation will also serve as baseline data for the JMC; the W RRO health care workers; the MCC and the various project members against w hich future evaluations o f the same projects could be measured.2.
To provide the project partners with motivational affirmation on the level o f community participation criteria thus far achieved.

3.
To indicate to the participants the mechanisms that should still be implemented (criteria still to be achieved) if they are to advance to higher levels o f com m unity participation on their own community health and developm ent pathway.4.
To evaluate the M H D P's implementation o f peoplecentred approach to community participation in PHC by evaluating the collective level (sum o f all the results) o f com m unity participation in the five sampled PHC projects.5.
To evaluate the collective level (sum o f all the results) o f the seven sampled community participation projects in M uldersdrift (five projects and the two m anagem ent structures).

Definitions • People-centred approach to community participation
The people centred approach, or the em pow erm ent approach as it is also called, is " a process by which the m em bers o f a so ciety increase thenpotential and institutional capacities to m o b ilis e a n d m a n a g e re so u rc e s to p r o d u c e s u s ta in a b le d is tr ib u te d im provem ents in their quality o f life consistent with their own aspirations" (K orten, 1990:67).A people-centred a p p ro a c h is one o f th e ra d ic a l development approaches and argues that participation can only be effective if it is com m unity driven (bottom-up), with the com m unity in control to decide about their own affairs and to develop the ability to m anage and utilise local resources for their own benefit (Barker, 2003:13).

• Primary Health Care
The ANC National Health Plan (1994:20) adopts the definition o f PHC as defined in the A lm a-A ta Declaration., 1994:9).

• Partnership
Stanhope and Lancaster (1988:257) define partnership "as the informed, flexible, and negotiated distribution o f pow er am ong all participants in the process o f change for im proved com m unity health" .In this research study the partnership concept, as defined by Stanhope and Lancaster is applied throughout.One o f the covert outcomes o f the community participation e v a lu a tio n is to p ro v id e th e p ro je c t partners with m otivational affirmation o f the level o f community participation thus far achieved (Barker, 2003:18).

Research design andmethod
T he research d esign w as ev alu ativ e, descriptive, quantitative and contextual.

•
The PHC project committee had at least one m ember who had achieved Grade 12 English.The rationale for this was that at least one m em ber had to be able to understand and com plete the tool on behalf o f the project committee.
In order to dem onstrate the extent o f the com m unity particip atio n in the PHC projects chosen, the total mem bership o f each project is presented together with the selected sam ple and the final sample (refer to  and O w en's (1994) standard evaluation instrum ent.T he evaluation tool was found to be understandable to all after a few ambiguous w ords were defined for clarity.
S tru c tu re d g ro u p in te rv ie w s w ere c o n d u c te d w ith th e PH C p r o je c ts ' executive com m ittee m em bers utilising Chetty and O w en's (1994) evaluation in s tru m e n t as b a s is .V a lid ity and reliability were ensured according to the criteria prescribed by Polit and Hungler (1997:657).Data collection was simple as th e ra n g e o f c rite ria fo r e a c h com ponent made it easy to choose, by majority vote, after group discussion, the most applicable criteria.The data was quickly and easily analysed and the re su lts fed b ack to the resp o n d en ts immediately.The level o f community participation attained w as p ictorially displayed (refer to Figure 1, Figure 2 and Figure 4) and explained.The discussions served to inform the participants about the fa c to rs in flu e n c in g co m m u n ity participation and that the results should not be seen as a score but as an indicator o f their increased (broadening) capacities and pow er over decision-m aking and resources in order to improve their health and life styles.The com ponent scores achieved by each project's participants were contextually discussed at the end o f each interview to provide motivational affirmation for the project's participants.The criteria still to be attained, in order to broaden com m unity participation to the nex t le v e l, w as th e n id e n tifie d and discussed w ithin the context o f each project.
The Joint M anagem ent C o m m ittee 's (JMC) data was collected via mailed self adm inistered questionnaires as Chetty and O w e n 's (1 9 9 4 ) in stru m e n t w as equally applicable as a questionnaire.This method was considered best for the JMC as they would score more honestly when alone with anonym ity ensured and it would minimise the time imposition on these busy professional officials.A report detailing the results was submitted to the JMC.Data analysis was not difficult as the three c o m p o n e n t s c o re s o b ta in e d w e re averaged to give the score for that factor which was then plotted on the relevant

Ethical considerations
The   Health Care Projects" .

Discussion of the results
The results are presented in accordance w ith the set objectives (1 to 5).The com parative graph (refer to figure 1) sh o w s th e le v e ls o f co m m u n ity participation achieved by the five PHC projects.
T  T h e M u ld e rs d rift PH C p ro je c t participants, who were represented on the Muldersdrift Clinic Committee, were able to broaden their community participation to between levels 3-4 (average 3) and through the process they increased their in stitutional capacities, but they had minimal success in forcing a shift in power over decision making and resources (refer to table 2).This previously very active committee, who had been so productive in broadening community participation through a wide range o f PHC projects involving m any different com m unity groups, had lost the pow er they had when enabled by the WITS Department o f Nursing Education.In addition the re s u lts o f th e J o in t M a n a g e m e n t Committee indicate that the Muldersdrift com m unity rep resen tativ es w ere not em pow ered and they felt they had no power.The Committee was disbanded in the latter part o f 2000 apparently due to disinterest on the part o f the members.This demonstrates the importance that the power over planning and resources must be in the hands o f the community participants if community participation is to be sustained.u n d e rs ta n d in g an d in s titu tio n a l capacities to identify their needs and to m ake the correct decisions relating to their health care.The com m unity was also partnered in th eir acquisition o f p ow er and in stitu tio n al cap acities to m obilise and m anage resources or to force a shift in resources so as to produce s u s ta in a b le a n d ju s tly d is tr ib u te d (equitable) improvements in their quality o f life , c o n s is te n t w ith th e ir o w n a s p ira tio n s .
T h is a p p ro a c h h as em pow ered the comm unity participants in the M H D P's PHC projects to a level, where they will be'able to implement the community participation process on their ow n using health professional/experts as reso u rces.H ow ever the level 4 for reso u rc e m o b ilisa tio n in d ic a te s that enablem ent o f a resource authority and experts was still required.Chetty and O w en's (1994) instrum ent entitled 'Criteria to evaluate Com munity participation in Prim ary H ealth Care P ro je c ts' w as chosen as it expanded Rifkin's, etal,. (1988:936) O w en (1994:3) that the instrum ent is valuable in providing feedback to the PHC p ro je c t p a rtic ip a n ts o n th e ir a c h ie v e m en ts and as a g u id e to the m echanisms they would have to take to achieve the next level.The intention o f the tool is to evaluate the participation level o f projects, however it is anticipated that through the evaluation, com m unity participation will be enhanced and project m em bers will be m otivated to improve over time.

Limitations
The limitations identified in the study, were:

•
The  The health professionals, the health resource authority and the M uldersdrift community representatives should discuss their approach to community participation to ensure com m itm ent to the projects.
For professional health care decisions, the community representatives on the JMC should be provided with sufficient information to empower them to make informed decisions.

The Muldersdrift Clinic
Com m ittee should be reformed to provide the PHC project members with a forum to: (i) assess com m unity needs, skills Evaluation at regular intervals should be conducted to provide m otivation and to utilise the instrum ent's criteria as a proactive guide towards broader participation.As projects are so different each project's participants should choose their own concurrent evaluation intervals.Broader community participation results in increased potential and institutional capacities to mobilize and actively participate in identifying their own needs, skills and aspirations eventually only using CHN researchers in advisory capacity.

•
A ssessm ent should be conducted at the end o f a project to establish summative evaluation o f community participation.
Evaluation o f their participation would affirm their developmental gains and enhance their dignity which in turn motivates continuing community participation. • Food gardens and first aid training were tried.But none o f the projects lasted longer than 6 to 8 months.The majority failed because the control and m aintenance o f the projects was entirely dependent on the students."It w a s n 't u n til th e n u rsin g sc ie n ce 37 Curationis June 2007 definition o f development as; " ... a process by which the members o f a so cie ty in crea se th e ir p o te n tia l and institutional capacities to mobilise and m a n a g e re s o u rc e s to p ro d u c e s u s ta in a b le and ju s tly d is trib u te d im provements in their quality o f life [or th e ir h e a lth in th e PH C c o n te x t] consistent with their own aspirations" .
stated that the indicators' value is tw o -fo ld .Firstly, the in d ic a to rs ' d e sc rib e d iffe re n c e s in c o m m u n ity participation over tim e and by different p e o p le .S e c o n d ly , th e y s tim u la te d is c u s s io n s a b o u t c o m m u n ity participation, which can help the people in v o lv e d in th e p ro g ra m m e s to understand the process better and thus assist them to achieve better results by allowing for greater involvement.

A
p le th o ra o f PH C p ro je c ts h a d evolvement from the community members involved in the MHDP from 1992, but there was a lack o f information on the e x c lu s iv ity o f th e c o m m u n ity p a r tic ip a tio n , as w e ll as a lack o f inform ation on how much com m unity o w nership there w as over d e c isio n m aking and resources.Thus at the start o f the Joint Management Committee's era o f management, the problem was a lack o f d ata on the level o f c o m m u n ity participation w ithin the MHDP.This problem leads to the research question that the research study sought to answer: "W h at w as the level o f co m m u n ity p articipation in Prim ary H ealth Care projects o f the M uldersdrift H ealth and Development Programme?" It reads: "Prim ary H ealth Care is essential health care based on practical, scientifically sound and socially acceptable methods an d te c h n o lo g y m ad e u n iv e rs a lly accessible to individuals and fam ilies in th e c o m m u n ity th ro u g h th e ir fu ll p a rtic ip a tio n an d at a c o st th a t the com m unity and country can afford to m a in ta in a t e v e ry sta g e o f th e ir developm ent in the spirit o f self-reliance and self-determ ination.PHC forms an integral part, both o f the country's health system and overall social and economic developm ent o f the community.Central to the PHC approach is full participation in p la n n in g , p ro v isio n , c o n tro l and monitoring o f services (NHP

Figure 1
Figure 1 Comparative levels of community participation achieved by the PHC projects of the Muldersdrift Health and Development Programme.

FactorFactorFactor
in g fu n d s a n d /o r resources C om m ittee/com m unity m em bers should take the leadership role in raising funds.R e so u rc e s m o b ilis e d from the community Level 3 = M oderate am ounts raised by committee.Level 4 = Large amount o f resources raised.Evidence o f com m unity voluntarily offering resources.Level 5 = Large amounts raised by means o f regular, planned fund raising initiatives and/or there is a regular source o f funds.e l 4 = C o m m itte e s e lf-m a n a g e d , ta k in g responsibility for the greater part o f management.Level 5 = C om m ittee/group should becom e se lf m anaged.Appropriated utilisation o f experts.Skills development Level 5 = Skills developm ent program m es extent beyond the project to com m unity members.Initial needs assessm ent Com m unity members in general are involved in needs assessm ent Skills identification Active identification and utilisation o f all skills O n g o in g re se a rc h and evaluation Com m unity/com m ittee utilises own skills to identify and carry out research.Researchers are used in an advisory capacity.
members take the leadership role in raising funds.The committee had raised seed money from Departm ent o f Social Services but needed to becom e self-sustaining by raising m onies through continued productivity o f high quality products and funds by developing m arketing strategies to increase their turnover and sales.R e s o u rc e s m o b ilis e d from the community Level 5 = Large amounts should be raised by means of regular, planned fund raising initiatives and/or a regular source o f funds.Control over allocation o f resources Level 5 = Committee has total control over allocation and utilisation o f funds.By becom ing self-sustaining the project would not have to be accountable to the Department o f Social Services.
T h e L e se d i Y o u th A s s o c ia tio n 's C om m ittee m em b ers still needed to achieve the criteria in Talbe B.The results o f objectives 4 and 5 will be presented concurrently.The level o f community participation in PHC, in the MHDP is graphically represented (refer to figure2).These results were achieved by e v a lu a tin g th e s e v e n s a m p le d community participation initiatives in the M HDP (the five projects and the two m anagem ent structures).The level o f com m unity participation achieved by the PHC initiatives, o f the MHDP, is an averaged level 4.This represents considerable achievem ents by the M HDP in broadening com m unity participation w'ithin the PHC initiatives.The level for each factor presented above (refer to figure2) was derived from the average o f the com posite com ponent scores (average o f the com ponent scores o f all sev en o f the PH C in itia tiv e s sampled) with the result that part-scores occurred (refer to figure3).The levels presented (refer to figure2) require further clarification as the lower scores achieved by the M u ld ersd rift C lin ic C o m m itte e a n d th e Jo in t M anagement Committee dim inished the scores achieved by the PHC projects a p p re c ia tiv e ly .C o m p a riso n o f the c o m p o n e n t sc o re s fo r e a c h PH C initiative (refer to table2) identified that these structure's scores w ere lower than the PHC projects in all components.In order to demonstrate these differences, the scores achieved by these parties are re-presented in Figure4(refer to figure4).The averaged scores o f the five (n=5) PHC p ro jects presen ted in F igure 4 re p re s e n ts th e M H D P 's le v e l o f com m unity participation enabled by the people-centred approach to community participation in PHC projects.The broad le v e ls o f c o m m u n ity p a r tic ip a tio n (averaged level o f betw een 4 and 5) indicate that the people-centred approach to c o m m u n ity p a r tic ip a tio n w as s u c c e s s fu l in e m p o w e rin g th e M uldersdrift community participants o f the PHC projects.In com parison the M uldersdrift Clinic Committee achieved slightly lower levels at between levels 3 and 4. The Joint Management Committee achieved between levels 2 and 3.

TFigure 2 .
Figure 2. The level of community participation in PHC projects in the Muldersdrift Health and Development Programme.

T
he J o in t M a n a g e m e n t C o m m itte e a c h ie v e d m in im a l b ro a d e n in g in com m unity participation to levels 2 to 3 (averaged 2.5) that indicates that the health professionals held the pow er over resources and took all the decisions.The h ealth p ro fessio n als/reso u rce holders re c o g n ise d th a t they d o m in a te d the com m unity representatives in decision m aking and m anagem ent.T he JM C members perceived that the Muldersdrift representatives had minimal power over resource allocation (Com ponent level 1 to 2) [Refer to table 2], A ssessm ent o f community and skills w ere c o n fin e d to th e r e s e a rc h e rs / resource authority.This indicates that th e JM C w as n o t c o m m itte d to community participation.Rifkin's (1981) public health approach to community can be identified in the JM C 's results.The M uldersdrift com m unity leaders were elected to m eet policy requirem ents; however the health professionals due to their expert knowledge retained the power over decision-m aking, resources and the id e n tif ic a tio n o f n e e d s and s k ills assessm ent.The narrow levels (averaged level 2.5) o f com m unity participation in the Joint M a n a g e m e n t C o m m itte e and the Muldersdrift Clinic Committee (averaged level 3) indicate that the M HDP's peoplec e n tre d a p p ro a c h to c o m m u n ity participation had not been adopted by th e h e a lth p r o f e s s io n a ls /r e s o u rc e authority responsible for the MHDP.The three partners i.e. the W RRO, WITS and the Muldersdrift representatives, had not discussed the concept com m unity participation and identified that they had d iffe ren t a p p ro a c h e s to co m m u n ity participation.They had not come to a consensus and made their choice o f an approach to com m unity participation explicit.The PHC projects com ponent scores (refer to table 2) identified that there were co m m u n ity le a d e rs w h o te n d e d to do m in ate and d id not allow all the members to participate or only consulted and reported back to the committee on an ad hoc basis.Community leaders who dominate, who do not consult and who are not accountable to the group, and w ho w e re e le c te d to le a d , do not contribute to com m unity participation.Such leaders are a danger to community p artic ip a tio n as th ey d ep o la rise the power from the poor and disadvantaged that they are meant to be leading on the path to empowerment.Such leaders have to be d e b u n k e d fo r c o m m u n ity participation to be successful.Chetty and Owen's (1994) evaluation instrument is an effe ctiv e d e b u n k in g tool as it id e n tifie s th e c rite ria re q u ire d by e m p o w e rin g le a d e rs to b ro a d e n p a rtic ip a tio n .A s th e c o m m u n ity p a rticip an ts e v alu a te th e ir p ro je cts, utilising the Chetty and Owen tool, they learn about the qualities o f good leaders
assessment tool to suit South African conditions.The instrum ent w as d esig n ed to evaluate individual projects but this study had extended its use to m ultiple projects within a program m e.In extending its function evaluation w as significantly im proved by analysing results o f the c o m p o n en t sco res and c o m p a ra tiv e factor level graphs.Chetty and O w en's evaluation instrument is recom m ended fo r th e e v a lu a tio n o f c o m m u n ity participation in individual PHC projects and for m ultiple PHC projects within a PH C program m e.The study results confirm ed the findings o f C hetty and

Figure 4 .
Figure 4. Comparative graph of the levels of community participation achieved by the Joint Management Committee, the Muldersdrift Clinic Committee and the averaged level of the five PHC projects enabled by the Muldersdrift Health and Development Programme.

Table 1 . Sample selection process and final sample Community participation PHC Initiative chosen Total membership of the PHC Initiative Selected Sample Final Study Sample
The CHN is in a managerial position responsible for the health o f the community thus both 'dow nstream '/episodic health care and 'upstream ' endeavours are her concern.Delegation o f community participation in PHC (community development) to Health Promoters, who are both trained and close to the community, is recommended but only if m anaged by the CHN.The CHN offer 'enabling resources' to the com m unity who will only access this 'enablem ent' if they know the 'what, where, when and how ' o f these resources.The CHN needs to market this 'enablem ent'.The lesson learned at MHDP is that the regular com m unity events needed to vary for example one m onth something recreational the next something serious i.e. budgeting.The lessons learned from organising the recreational activity for example traditional dance contest could be used at the basis for the next months budgeting lesson i.e. fun, reality based, need orientated learning activities motivated more and more community participation.