Contextual Factors
Community-based programs can work usefully, bringing steady progress; whether they do depends on myriad factors relating to the context. Three different concerns are (a) factors affecting widespread initiation of CHNPs of potentially adequate coverage, intensity, and content; (b) factors that lead to sustainability; and (c) factors that allow activities to be effective in improving health and nutrition—at best, when they, themselves, also contribute to a rapid transitional improvement, as in Thailand, Costa Rica, and Jamaica.
Contextual factors may bring about improvements in health and nutrition without any additional direct action—through improving living conditions, education, and so forth. Often, the changes caused by such nonprogrammatic factors are difficult to distinguish from program effects (current examples are in Bangladesh and Vietnam, both showing rapid improvement in nutrition). Moreover, the same factors (again, such as education) may both produce endogenous change and increase the effect of program activities.
Five contextual factors have been suggested as priorities (in Asia; Mason and others 2001):
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women's status and education
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lack of social exclusion
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community organization
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literacy
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political commitment.
Table 56.4 shows estimates of the positions of countries with case study programs in regard to these factors. The levels of health and administrative infrastructure have been added. The table also shows changes in these factors that may help explain why the CHNPs declined in three cases.
[Table .]
Political commitment can lead to initiating community programs and mobilizing resources. It may also respond to emerging community mobilization, as seems to be the case when programs start after political upheavals, as in Zimbabwe and Nicaragua. Declining political commitment accounts for loss of interest by the government in CHNPs; economic decline undermining resource availability may cause a shift away from financial support of CHNPs (for example, in Tanzania). In table 56.4, estimates of levels of contextual factors are totaled both without and including political commitment (last two columns). The total without commitment may indicate how favorable the context is if commitment is then made. Costa Rica, Jamaica, and Thailand had a favorable context and, with commitment, succeeded. The Philippines had comparable favorable conditions—the position of women is generally good, there is limited social division (exclusion), and so on. However, the necessary commitment (of resources, in particular) was made only recently, with new legislation, adherence to regulations (for example, iodized salt went from 25 to 65 percent coverage), and increased resource allocation and assignment of community workers. This new commitment may well explain the recently resumed decrease in child malnutrition (figure 56.2). In other examples—such as Indonesia and Tanzania—the conditions were moderately favorable, and while political support and finance existed, progress was made. In Tanzania, financial crisis denied the programs sustained support; in Indonesia and Zimbabwe, bureaucratization and centralization of the political process, followed by political turmoil, contributed to a similar outcome (Sanders 1993). The situations in India and Bangladesh have not been very favorable. The position of women and social rifts, amounting to exclusion, have probably inhibited effective programs, even with political commitment. This context may now be changing in Bangladesh, as seen in the activities of BRAC. Finally, this analysis demonstrates the relation of decline in programs to falling political commitment in Tanzania, Zimbabwe, and Indonesia.
If this analysis approximates the truth, the forward-looking policy implications may be important:
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First, investing initially in a favorable context makes sense (as does possibly committing resources preferentially to interventions in the more favorable contexts). Supporting policies can address social constraints—such as improving education for women—and (relatedly) seek to improve human rights. In many cases, human rights may be of overriding importance for health: Farmer (2003) has made a compelling case for rethinking health and human rights as a prerequisite for progress and as a responsibility for those working for health, especially of the poor and of the destitute sick. This investment may be long term and difficult—as in Kerala, India, for instance—but must be seen as integral to the struggle for health (Sanders 1985). Operationally, this commitment to human rights puts greater responsibility on advocates and investors in health to broaden the dialogue and scope for allocating resources and to avoid committing resources regardless of the prospect of success as influenced by the social and human rights context. In health and nutrition, as in other areas, adjustment of policies to support the success of interventions would be pragmatic as well as the right thing to do.
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Second, even if the context is more favorable, genuine political commitment is still essential. Excessive donor input may inhibit this commitment. It is striking that Thailand had to reject donor influence and make its internal decisions before its programs became successful (Tontisirin and Winichagoon 1999), Costa Rica had to fight and overcome a medicalized approach (Munoz and Scrimshaw 1995), and Indonesia's posyandu system was undermined when treatment displaced prevention (Rohde 1993).
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Third, it is clear that severe economic stress, political pressure, or both have caused unsustainability (Indonesia, Nicaragua, Tanzania, and TINP).
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Fourth, if the context is unfavorable, it might be better to work on improving the context than to commit resources to programs that may not succeed—but, of course, success in improving context itself depends on circumstances, notably political commitment.
Considerations like these should contribute to identifying supporting policies needed for programs to be effective and modifications to interventions in particular conditions. For example, it is often observed that a particular factor—say, access to health services—is more strongly related to improvement among the better off (for example, the educated) population. This interaction of program with context leads to identifying new needs—in this example, perhaps facilitating access for the illiterate. In the longer run, resources or legislation (for example, to combat social exclusion or discrimination against women) may be highlighted as prerequisites before a program can be expected to work. Often failure to take account of context when trying to transfer experiences from a pilot trial ("scaling up") may explain why efficacious interventions prove ineffective in a larger population.
This analysis of contextual circumstances indicates that targeting the poor may not always be cost-effective, and some interventions may not be feasible in certain contexts. An example is when the health infrastructure and services are almost nonexistent; under those conditions, it can be argued that emergency treatment (especially for the diseases addressed by IMCI) should be established and reliable resources put in place first. A similar difficulty, often seen in food security, is that most interventions may not work for the poorest of the poor. For instance, supporting food (or cash crop) production in low-potential areas may not be realistic; nonagricultural employment may be better.
Thus, community-based programs work in a specific time and place: programs may start, work for a time, and then evolve or fade away. Even if they fade away, some useful effect may be achieved: sustainability need not be forever. At the same time, short project cycles (three years for many donors) can act against sustained programs. Some compromise in donor policies to allow assurance of continuity for reasonable periods (such as 10 years) could do a lot to increase the effectiveness of donor support to CHNPs.
The essence of time and place is not fully understood. Werner and Sanders (1997) give examples of favorable times, as when the old order is changing (for example, after internal conflict, as in Nicaragua and Zimbabwe) and when there is renewed vigor and some new organization is in place. Another generalization of a favorable context is when energy and inter-connectedness exist in society. Thailand illustrates both: the Thais needed to change the approach, moving away from donor influence, in order to initiate the successful community programs that helped transform health and nutrition throughout the country, and that worked in part because of cohesive features of Thai society (Tontisirin and Winichagoon 1999).
In these examples, programs that continued on a large scale—either until the problem was largely resolved, as in Costa Rica, Jamaica, and Thailand, or as it was expanding, as in BRAC in Bangladesh or AIN-C (Atencion Integral a la Ninez Comunitaria) in Honduras—clearly had supportive context, but their specific common features (and hence how they could be replicated) are elusive. Perhaps one crucial condition for success is that circumstances are such that people and communities begin to have the sense that they can take responsibility for—and control of—their health and quality of life. Responsibility comes with the emancipation of societies from colonial or other repressive conditions and possibly when grassroots attention becomes widespread, as it did in Bangladesh through an NGO that identified with the people. Evidence is growing that, among the poor in the United States, this sense of control is directly related to better health and reduced exposure to HIV and AIDS; Sampson, Raudenbusch, and Earls (1997) call the concept collective efficacy. Cohen and others (2000) show that health conditions improve when communities themselves fix up their environment—the "broken windows" theory. Such ideas may equally apply to poor communities, especially urban ones, in developing countries too.
