The Function and Impact of Women '$ Organizations on Community Development and Rural Primary Health Care Literature Review Wonen's Organizations Eivfower Their Ivewbers with Skills Community Development, Community Participation and Health Methodology the Setting Background Information on the Two Sel

"Women's organizations by virtue o f their existence are associated with community advancement" Introduction When one explores the health problems of developing countries such as South Africa, the importance of primary health care becomes clear. The multiplicity of the health problems coupled with the lack of resources makes it imperative for govern­ ment within the primary health care approach to call upon communities to partici­ pate in the solution thereof and community participation and development inherent in primary health care become the key objectives to realize and sustain a healthy living. However, without structures and processes to involve the community in their own health, the ideal of health for all embodied in the concept of primary health care will not be realized. One strategy for such participation is for primary health care workers to facilitate the organization of women into development-focused groups in the community. Women's organizations by virtue of their existence are associated with community advancement. They are usually formed as a response to a need to meet activities for daily living. The activities are usually directed towards improving the communi­ ties' way of living through better health and income generation; and the organiza­ tions serve as a link between other organizations and the community. This is a study to address how such wom en's organizations are organized and what contributions they make to the life of the individual member and the community. Primary health care by virtue of its defi­ nition calls upon communities to provide for their own needs. It requires of gov­ ernments to be com m itted to the im ­ provement of people's conditions of liv­ ing by passing legislation that enables people to be m eaningfully involved in their own care. In their report Annet and Nickson (1991) stated that as early as 1970 decision makers had already be­ come aware of the need to make devel­ opm ent people-centred based on the people's own ideas, actions and partici­ pation. The World Health Organization (WHO) (1976) presented participation in decision making as a basic human right which all people should enjoy because it enhances self esteem and increases a sense of responsibility. Given the above explanation it is clear that com m unity participation, personal interaction and human solidarity are in­ heren t in c o m m u n ity d e v e lo p m e n t. Women by …


Introduction
When one explores the health problems of developing countries such as South Africa, the importance of primary health care becomes clear.The multiplicity of the health problems coupled with the lack of resources makes it imperative for govern ment within the primary health care approach to call upon communities to partici pate in the solution thereof and community participation and development inherent in primary health care become the key objectives to realize and sustain a healthy living.However, without structures and processes to involve the community in their own health, the ideal of health for all embodied in the concept of primary health care will not be realized.One strategy for such participation is for primary health care workers to facilitate the organization of women into development-focused groups in the community.
Women's organizations by virtue of their existence are associated with community advancement.They are usually formed as a response to a need to meet activities for daily living.The activities are usually directed towards improving the communi ties' way of living through better health and income generation; and the organiza tions serve as a link between other organizations and the community.This is a study to address how such wom en's organizations are organized and what contributions they make to the life of the individual member and the community.

Literature Review
Primary health care by virtue of its defi nition calls upon communities to provide for their own needs.It requires of gov ernments to be com m itted to the im provement of people's conditions of liv ing by passing legislation that enables people to be m eaningfully involved in their own care.In their report Annet and Nickson (1991) stated that as early as 1970 decision makers had already be come aware of the need to make devel opm ent people-centred based on the people's own ideas, actions and partici pation.The World Health Organization (WHO) (1976) presented participation in decision making as a basic human right which all people should enjoy because it enhances self esteem and increases a sense of responsibility.
Given the above explanation it is clear that com m unity participation, personal interaction and human solidarity are in heren t in c o m m u n ity d e v e lo p m e n t.Women by virtue of their nature are pre disposed to interacting with others such as fam ily, spouse, ch ild , neighbour, fellow m an etc.In projects m eant for community upliftment women find them selves available as well as forming an in terest group.One example is the Self Employed Women's Union (SEWU); an organization established by the Durban street hawkers.The organization attends to problems encountered by women in relation to police harassment when con ducting business in the streets, sanitary environment for the hawkers, banking of small amounts of money sometime as little as R1.00.The women are making a contribution to the country's economy and they are a big tourist attraction es pecially in the Durban beach front area.Such women's organizations are found throughout the world.Sebstad (1992) reports of India's Self Employed Wom an's Association (SEWA) in Amehdabad, India.This organization is mainly com posed of illiterate women whose main production is from household goods, and business is home-based.The prod ucts may consist of garden produce and/ or chickens and chicken products.Sales

WONEN'S ORGANIZATIONS EIVFOWER THEIR IVEWBERS WITH SKILLS
are small and from headloads that are carried from house to house.It is also interesting to note that SEWA has grown from strength to strength and has be come successfully commercialized with the high illiteracy rate serving as a criti cal aspect in positively identifying and strengthening the organization.
In a study conducted by Mfono (1989) rural women in Venda were found to form a large com ponent of unpaid labour force especially because the tasks ad dressed wom en's activities for daily liv ing e,g housekeeping, childminding and agriculture.In this study Mfono (1989) also shows that fam ily health ranked high a m o n g st the needs o f w om en hence their willingness to be involved in th o s e e n d e a vo u rs th a t e n h a n ce d healthy behaviours e.g health education program m es on prevention and treat m ent o f d ia rrh o e a and d e h yd ra tio n thereof.

Community development, community participation and health
C om m unity developm ent can be de scribed within comm unity participation because it is a process of development where the community becomes involved in activities that they are concerned with, decide on priorities, select realistic goals and take resp on sibility fo r decisions made.In a description given by Rifkin, Muller and Bichmann (1988) community participation is stated as " a social proc ess whereby specific groups with shared needs, living in a defined geographic area actively pursue the identification of their needs, take decisions and estab lish mechanisms to meet these needs" (Rifkin et al, 1988, p.933).This explana tion gives the meaning of 'com m unity' and that of 'participation'.It emphasizes the commonalities of groups and prox imity of members for easy contact and action in com m unity developm ent un dertakings.M inkler (1992) also sees community development and participa tion as a process by which individuals, com m unities and organizations gain mastery over their lives.Women's organi zations by virtue of the choice of their activities empower their members with skills in organization, leadership and management.
The activities of traditional birth attend ants are some of the well known activi ties of women.These are small groups of women living in the same geographic area.They organize themselves to as sist other women during childbirth espe cially in rural areas.Chipfakacha (1994) reports that over two thirds of births in the world are conducted by traditional midwives.In his study he points out that 81.6% o f th e s a m p le s tu d ie d from Kgalagadi, Botswana, preferred home deliveries by traditional birth attendants because of financial benefit, privacy, comfort, protection and proper disposal of the products of conception and unin terrupted care of the family during con finement.The Care Group and Akanani are two w om en's organizations m ainly estab lished to improve the quality of life and the health of the wom en's families and those of communities they live in.The tw o organizations are located in the Northern Province,South Africa.To fully participate in the program m es the lit eracy rate of these women needs to be attended to.Members of Akanani have to increase their skills on numeracy so as to m eaningfully participate in the budgets of the organization and those of the area.The Care Group women have to increase their reading skills so that they can gain access to health in formation and be able to confidently in terpret health messages to their coun terparts.

Methodology The Setting
Elim is integrated into Venda in the North ern Province, South Africa within the con fines of a district known as Hlanganani.It has thirty seven villages.The most re cent census figure (1994) on population was stated as 148 200 of mainly Tsonga speaking people.The area is entirely rural with no industries.Family income is generally low and unpredictable as it depends on money sent by husband/ father/son/brother working outside the area and on occasion seasonal employ ment of women in the surrounding agri cultural farms.Summer rains are by far the main source of water and people depend on this rainfall for their crops.Subsistence is mainly on maize and pea nuts.Farmers who have installed irriga tion schemes grow a variety of vegeta bles and sell to the inhabitants of Elim.The disease pattern is typical of devel oping countries throughout the world.Preventable infectious com m unicable diseases and malnutrition are predomi nant and trachoma is endemic.

Research Design
In the quest for information on how wom en's organizations are organized and contribute to com m unity development and health, a case study design was used and qualitative data collected to provide the needed inform ation.Two w om en's organizations were chosen.These form ed form ed the case to be studied.The both organizations were active in the same rural area of Elim.One, the Elim Care Group Project, was health focused, and the other, Akanani Rural Development Association, focused on income generation,.Seeing that each organization had branches that operated in various villages, the branches served as embedded cases of the main case.Five active branches were selected from each organization as embedded cases based on their: progressive programmes a history of success in the com munity and increasing membership

Background Information on the Two Selected Organizations Elim Care Group Project
The Elim Care Group Project is a wom a n 's organization that is focused on health and health information propa ganda.It serves as a direct link between the health services in the area and the community.According to Ballard, Sutter and Fotheringham (1978) the organiza tion was established in 1976 in Elim, Northern Province, South Africa.Its ini tial aim was to eradicate and control the occurrence and spread of trachoma, an infective endemic blinding eye condition in the area.As soon as the organization was established it became apparent that, for the trachoma to be controlled personal and environm ental hygiene had to be attended to because flies were found to be vectors that carried infection from one person to the other; and shar ing of face cloths and sleeping areas resulted in individuals infecting each other.The m edication that was used then could only be obtained from the hospital.Doctor Sutter working in the o p h th a lm o lo g y clinic, Elim H ospital; Selina Maphorogo the assistant nurse working with her and Andrew Radebe the hospital social worker decided as a team to go to the community to inform the people a bo ut the causes of tra chom a.In the co m m u n ity the three made a plea for volunteers to come for ward and take the eye medicine and apply it into the eyes of those affected as there were far too many people suf fering from trachoma than were means from the hospital to treat it.The volun teers would be taught how to diagnose, treat and prevent trachoma as well.Ini tia lly g ro u p s of 15-20 w om en were fo rm e d fro m th re e v illa g e s .These women moved in groups from house to house diagnosing and treating trachoma and teaching households about preven tion thereof.To extend coverage, each of the 15-20 women were allocated ten (10) households to take care of .From this came the concept of 'Care Group'.
The group was managed and based in Elim Hospital.

Akanani Rural Development Association
Akanani Rural Development Association

Data Collection
A case protocol was used to increase the reliability of data collected and to en hance convergence of evidence in cases of triangulation.The protocol was d i vided into three sections: SECTION 1: This was for the key inform ants i.e directors, supervisors, p ro gramme/project managers and coordi nators, sponsors and motivators.The inform ation required covered specific executive topics relating to organization and function of the organizations.
SECTION 2: This was for the focus groups/the embedded cases.The ques tions related to the organization and function of the branches in the villages and how individual members have ben efited by belonging to the group.Infor mation from this section served to indi cate similarities and differences between branches as well as between organiza tions.

SECTION 3:
The last section contained questions for community leaders to find out the contribution of the organizations as perceived by the community.
The protocol was used in the intensive interview with the various people.Other sources of inform ation w ere pro je ct d o c u m e n ts e.g p ro je c t p ro p o s a ls , memoranda, progress and annual re ports, newsletters, newspaper clippings, agenda, minutes of meetings, local sta tistics, publications, photographs, per sonal diaries, letters, maps, charts, cer tificates, audio tapes and video tapes.These were reviewed.Direct observa tion was also made during the visits and field notes compiled.Physical artifacts and tabular material in the form of mem bership badges, uniforms, com pleted projects, general communal productions and ornaments were observed and as sessed.
Permission to conduct the study was sought and obtained from the Provincial authority, the management committee of each of the organizations, the chiefs of the various villages where the branches were operating and from the key inform ants including the focus groups.
To collect data, interviews were co n d ucte d and a c tiv itie s observed and documented for analysis.As the com munity spoke Tsonga, an experienced research interpreter who resided in Elim w as e n g a g e d .The in te rp re te r had worked with many research groups com ing to the area and as such had a good knowledge of research principles.Collection of data extended over three weeks.

Elim Care Group Project
The office of this organization was situ ated in the com m unity health depart ment at Elim Hospital.The key inform ants were also the executive manage ment of the organization i.e the direc tor, project coordinator and motivators.These were health personnel employed by the Department of Health seconded to the project.The focus of the organi zation was in health.
The key informants verified the informa tion on the establishment of the organi zation.They also added that on ventur ing into the community; Dr. Sutter, Selina Maphorogo and Andrew Radebe soon came to know the causes of cross infec tion and reinfection.The three had found that grandmothers and children shared sleeping mats or mattresses and wash ing cloths hence their clients were mainly children and their grandparents.They also came to understand why the dis ease was rife but accepted as something that had to occur.They found that in the community people believed that: • young children must have dis charging eyes sometime in their early life to can see better at a later stage.When children were affected by trachoma and had discharging eyes mothers thought that it was the nature's way of improving their eye sight.
• young women must immediately inform their mothers-in-law about their pregnancy once they were aware of it.Failure to do so may result in the child or the grandmother or both becoming blind as punishment by ances tors.
They also came to associate other fac tors with the disease.There were no rub bish dumps in the village and litter was in abundance.Flies were all over the households.They also realized that the living conditions were to change if they were to combat trachoma.In the villages, they discovered overwhelming poverty that was the cause of ill health.Clean areas were found where people with in come lived.
Getting into the com m unity informed them of other concerns that people had.These were the incidence of diarrhoea, respiratory tract infections, malnutrition, worm infestation and impetigo.

This information is captured in a video cassette kept at Eiim Hospital
The organization therefore aimed at in forming communities about the causes, consequences and prevention of tra choma, diarrhoea, respiratory tract infec tions, malnutrition, worm infestation and impetigo.The organization also informed communities on ways of improving their living conditions including health.They informed them about family planning, immunization, weighing of babies as a way of assessing the nutritional status of children, aspects that interfere with infant nutrition and treatment and pre vention of dehydration am ongst diar rhoea sufferers.The organization sought support from community leaders where upon chiefs would call mass meetings and create a platform for the hospital team to present their views and invite contributions from the community.In this way volunteers to treat trachoma and all other ailments were identified.Vegeta ble gardens and poultry farm ing were started to combat malnutrition, cleanli ness cam paigns including building of toilets and digging of rubbish dum ps (amagoji) were initiated and maintained.
To attend to the incomelessness, the women formed groups and made bricks and sold these to people wanting to put up cement brick houses and toilets.In some instances the women would get together to work in a communal garden under the assistance of the agricultural officer (murimisi).Vegetables realized from the garden would be used by mem ber households and also sold to the community at a very low price.
As most of the wom en's time in Elim , like in all rural areas, is taken up by the search for water and fuel, the organiza tion taught the women on how to ad dress the issues of water and energy source.With these issues out of the way there would be time spared to clean their houses better.They were taught how to make and use wonder boxes.The agri cultural section together with the chiefs helped them to dig boreholes and build reservoirs.This provided them with the much needed safe drinking water and reduced the in c id e n c e o f d ia rrh oe a whilst helping them to irrigate their gar den produce.Branch meetings were held every week on Tuesday in the afternoon.Principles of formal meetings were observed.Each branch had an executive committee that consisted of: a chairperson, vice chair person, secretary, vice secretary, treas urer and two additional members.Each woman in the branch was to take care of ten h ou seh old s by in fo rm in g the households about health and ways of healthy living e.g.assist them in con structing a toilet, help them dig a dum p ing pit, assist them to keep themselves and their homes clean, teach them how to prepare the rehydration solution and how to administer it in cases of diarrhoea and d e h y d ra tio n , e n co urag e breast feeding and inform women on proper nutrition of family members with empha sis on infant nutrition..The woman had to assist them to establish a vegetable garden.The activitie s o f ind ivid ua l w om en were recognized by initiating these women into the group in a gradu ation ceremony.A headscarf would be given to the women who have graduated to the membership of the Care Group.C om m unity leaders were know ledge able about the activities of the organiza tion.In many instances they were in volved in the initiation of projects, and chiefs in particular supported the organi zation's undertakings.
This organization also helped women to relate b e tte r w ith one a n o th e r and through this cooperation, unity and shar ing not only of ideas but of material pos session developed am ongst villagers.C lea ne r s u rro u n d in g s e s p e c ia lly at home and healtheir children were appre ciated by husbands who expressed this by in cre a sin g th e ir v is its from th e ir workplaces.This assisted in maintaining the family structure otherwise disrupted by migrant labour.

Akanani Rural Development Association
The office of this organization was situ ated at Shirley farm, about seven (7) kilometers from Elim Hospital.
The key informants were the d irector of the organization and th e p ro je c t m anager.These verified the establish ment, organization and func tion of the organization.It was also heard th a t Mr C o llin s taught managers how to write funding proposals.The initial project was spear-headed by Mrs Collins who had observed that the w om en in the area were artistic as demonstrated by the decorations on the in side and outside of the walls of their rondavels.She intro duced cloth painting translat ing the patterns from the walls onto cloth.Under this initiative two textile industries, Tiakeni and Twananani, and other craft coop eratives were established as models for development.Women were taught to cut cloth according to pattern books, sew and sell clothes to the public.The organi zation also conducted literacy classes and taught women principles of produc tion and marketing.From these, other needs were identified, like that of improv ing building materials used so as to put up solid safe houses that are also easy to clean.The women were taught brick making and brick laying, weaving and pottery.In this way money could be gen erated from other people other than those in Elim.Individuals as well as groups were assisted to set up small businesses.The weavers made wall and floor rugs as well as jerseys.The women doing weaving were introduced to the National Craft Association of South Af rica.This association assisted them to identify relevant markets for their goods.
At the time of investigation the organiza tion, Akanani, was also helping the fruit and vegetable hawkers to build a mar ket place where business could be con ducted decently and comfortably.
Akanani groups were fairly small as most of the women went their different ways once trained.The organization was also willing to help individuals.In those cases where women got together to form cooperatives the members were eager to get their products on to the market.There were no regular meetings.Mem bers met only when they felt a need and this could be a long time.The manage ment committee served to mainly ensure that the environment was conducive for members to work in; so, during the few m eetings there w ould be reports on equipment, cleaning up operation and toilet facilities available to members.
Community leaders did not know much about the organization and its activities.
Those that had an idea were not sure of the operations therein.

The Impact O f The Organizations
From the interviews with the key inform ants, the inform ation from the d ocu ments, videos, audio tapes, physical ar tifacts and field observation the organi zations had each kept its focus and had contributed to the improvement of living conditions in the community.At the time o f in v e s tig a tio n th ro u g h the C are Group's activities trachoma was seldom seen at Elim.Nearly every household had a latrine and a rubbish dump.There was piped water within 5 km walking dis tance for every household.On observa tion the nutritional status in the village was satisfactory.
Even though the main building material was still mudbricks and grass for roof ing, there were many houses built of cement bricks and corrugated iron roof ing.Some of the houses belonging to Akanani members had electricity, which factor improved their quality of life be cause there was amongst other things reduced flo o r dust and sm oke from cooking fires.
Individuals had learnt life-long skills which they would not have done had they not belonged to the organization.Both individuals and communities attrib uted the improvement in sanitation, nu trition and health to the organizations' effort, especially the health focused or gan iza tion .In the study, the people stated that the construction and use of toilets and the digging of rubbish dumps had greatly reduced the flies which are agents in disease transmission.The es tablishment of communal gardens, poul try farm ing, awareness cam paigns in nutrition and im m unization, im prove ment in the construction of dwellings all contributed to the prevention and reduc tion of disease.In accordance with Addo et al (1985) it could be stated that the history of Hlanganani was unfolding and the people were gradually being acculturated and transform ing to western standards.
What was also found was that the Care Group had much more cohesion than Akanani.The Care Group received much support from the com m unity as it ad dressed concrete problems.The origin of the organization was better under stood by the people and in many ways acceptable as the people were involved from the start.The management struc ture was strongly supported by the gov ernment and provided a stable core.The uniform that the w om en had and the ceremony that was held to inaugurate members served to strengthen the bond am ongst m em bers and between the members and the community even fur ther as these took a form of regional fes tivities.
There were factors that negatively af fected the org an izatio n's fu nctio nin g though.One of these was the close re lationship of the organization with the government that sometimes interfered with the organization's charitable func tioning.The fact that the executive was made up of fully employed people meant that they sometimes were not be able to undertake tasks they were expected to perform as they had to put in a day's work for a day's pay.
Akanani on the other hand was com pletely non-governmental even though there was an indirect governmental in put in the educational programme.The Department of Education had to regis ter the matriculation students receiving tuition from the organization.At the time of investigation, the organization was not well supported by the com m unity be cause the initiators did not introduce their intentions through acceptable channels i.e chiefs.It was an initiative of a white man and this coincided with the political uprisings of the 1980s in South Africa.The offices were in the premises of a white farmer.The people became sus picious ,and, because the people were not at the time, in the habit of entering the white m an's premises without per mission, the organization was already inaccessible to the ordinary black per son.During the 1985 political uprisings, politically active youths sought refuge in the offices.This action identified the or ganization with the then banned African National Congress and as there were policemen 24 hours around the clock at the place, older folk were afraid to associate with the organization.This is evidenced in the response of com m u nity leaders who are fairly old and at the time of investigation it still served as a perceived weakness in the functioning of the organization.

Summary o f the Discussions
There seemed to be a number of fac tors which strengthen the organizations studied.For the Care Group these were: the presence of a full-time director who was a medical doctor and had a high status in the community, a centralized executive m anagem ent that included community members and was linked to the m ost utilize d Elim H ospital.For Akanani the a b ility to generate own funds and improve literacy served as great strengths for the organization.The organizations had addressed some key elements of prim ary health care.They had provided for health education especially of the prevailing conditions, nutrition and food provision, sanitation and supply of adequate safe water, fam ily planning and immunization, control of comm unicable diseases and provision of essential drugs.
The factors which tended to weaken the organizations were their strong links and association with a controversial govern ment and other structures and their in ability to meaningfully generate income.For Akanani members the other factors that contributed to it being perceived as weak were lack of managerial skills, lack of identity as a group and poor support of members by the main organization.