Collaborating with Pagodas and Mosques In

Community participation in health

Collaborating with pagodas and mosques in

Kirivong Operational District

Working paper 6

Summary

Like many developing countries, Cambodia has embarked on a Primary Health Care approach as the most effective way to achieving accessible, equitable, quality health care for its population. A core principle is the promotion of community participation in the development of appropriate local health services and community development activities. This provides people an opportunity to influence health services as well as a responsibility to manage their own health problems through greater health awareness and community actions (MoH 2000).

Pagodas represent an existing and influential structure for community participation in Cambodia with institutional capacity and the ability to generate considerable resources through voluntary contributions. Their extensive grassroots networks are highly conducive to mobilising and motivating people and a cadre of existing volunteers are active in the community.

In late 2001, Enfant&Développement established a structure for large-scale community participation in Kirivong Operational District through collaboration with the network of 91 pagodas and 5 mosques, and their associated volunteers, along with official authorities. Two mechanisms were established. Health Centre Management Committees were formed at each health centre to facilitate community involvement in decision-making at health centre level and provide a means for information flow between the health centre and the population. Health Action Groups work at village level with responsibility for community-based health activities including health education and nutrition programs. Health staff have a prominent role in training, implementation, supervision and monitoring of programs.

Developing capacity for community participation is a long term process. Still, after one year of activity, significant improvements have been observed in the uptake of preventative services as well as maternal and child health knowledge amongst target groups. These results strongly indicate improved community participation has been achieved through active cooperation between health staff, pagoda and mosque volunteers and local authorities. The experience so far suggests that pagoda committee and mosque structures possess the capacity to provide leadership for community participation in health and the development of primary health facilities, including the potential to initiate, manage, implement and resource health activities.

Introduction

Enfant&Développement (E&D) has been contracted by the Ministry of Health (MoH) from 1999-2003 to manage and administer health services for Kirivong Operational District (KOD), including the delivery of preventative and curative healthcare from 20 health centres and one referral hospital. While significant reforms had occurred since contracting commenced, in 2001 there was still little confidence in the health system, and limited community health awareness or involvement. A key objective became to establish community participation with the aim to 1) give the population a voice and make health staff accountable and responsive to their needs and 2) raise health awareness to improve health behaviours and utilisation of services. KOD consists of 4 administrative districts, 31 communes, and 290 villages with a population of about 205,000 people. A key consideration in developing a strategy for community participation was the large coverage area making it difficult to work directly at village level. In late 2001, an approach was initiated to promote collaboration between the operational district, official authorities and religious institutions and their associated volunteers. This paper describes the process, rationale and experience of establishing a structure for large-scale community participation in KOD working with pagodas and mosques.

The health sector in Cambodia

Only recently, Cambodia emerged from 30 years of civil conflict. The Pol Pot regime alone claimed almost two million lives during 1975-78, creating massive social upheaval and a complete breakdown of existing national institutions and social infrastructure. A lasting legacy of poverty, widespread malnutrition and illness ensued and many fled the country (Brown 1999).

Cambodia's health indicators remain amongst the worst in the region. The infant mortality rate has risen since 1990 to 95 per 1000 live births, nearly double the rate in Indonesia and three times that of Vietnam. The maternal mortality rate is estimated at 470 per 100,000 women. Malnutrition is widespread, affecting about 50% of children aged 6-59 months and about 20% of women of reproductive age. Almost 85% of the population is rural with a high proportion of households having no access to safe drinking water or sanitation (Royal Government of Cambodia 2002).

The current Ministry of Health was established only in 1993 starting from virtually a zero base. Since then, considerable progress has been made to develop the health system and its infrastructure. But, the public health sector remains fairly weak, suffering from insufficient funding and a lack of human and physical resources. Government spending on health was only $3 per capita in 2001. There are insufficient numbers of trained doctors and nurses, especially in rural areas, and low salary levels divert health staff to the private sector for additional income (MoH 2002). About 47% of the population do not have ready access to adequate public health services (Royal Government of Cambodia 2002). Still, the demand for health services is evident. Medical expenses account for around 30% of family expenditure, mostly incurred through the prolific, expensive and unregulated private sector (ibid).

Low utilization rates of public health services are mainly attributed to poor physical access to facilities, staff discontent, and a general lack of community confidence in the quality and the cost of care. Furthermore, the health seeking behaviour and health practices amongst the population reveal low levels of health awareness. The National Policy on Primary Health Care sets out six key principles to achieving equitable and accessible quality health care:

Universal accessibility and coverage in relation to need
Community participation in health and development
Inter-sectoral action in health
Appropriate technology and cost effectiveness
Sustainability
Monitoring and evaluation

Community participation is recognised as one of the key ways to improve the population’s health status and the functioning of health facilities. An inter-sectoral approach to primary health care is advocated through inter-Ministry cooperation, involvement of authorities at each level, and utilising a number of community support structures [eg. Village Development Committees (VDC), Commune Development Committees (CDC) and Village Health Volunteers (VHV). Two key community participation structures for the development of the health centre are the Health Centre Management Committee (HCMC) and the Village Health Support Group (VHSG). (see National Policy on Primary Health Care (2000), Health Sector Strategic Plan 2003-2007 (2002), Policy on Community Participation... (2003)].

Community participation in KOD through collaboration with pagodas and mosques

For community participation to be successful and sustainable initiatives must build on communities' own structures and experiences. Political and social relationships must be understood and appropriate community actors identified (Zakus and Lysack 1998).

Community participation in Cambodia is debated. Some commentators suggest that traditional Khmer society was individualistic whereby mutual assistance did not extend beyond the family (Kiernan 1996, Van de Put 1995). In recent times the legacy of years of conflict, particularly during the Khmer Rouge regime, is thought to have perpetuated widespread mistrust and tension within society and a resistance to all forms of collective organisation (Brown 1999). On the other hand, there are examples of mutual assistance at neighbourhood level, including reciprocal labour or goods exchange, interest-free loans, rice or cash associations, and community construction activities. Historically, many of these forms of community organisation are activated through the Buddhist pagoda, which performs many functions in the religious, cultural and social life of the village (Aschmoneit et al 1998, Collins 1998, Brown 1999). The pagoda is a place of worship, a refuge for the poorest and disadvantaged, a repository of knowledge and culture, a lay court to resolve disputes, a healing place for the sick, and the site of many significant religious and social ceremonies (Brown 1999). As such, pagodas represent an influential existing structure for community participation that is well organised, experienced and rooted in tradition.

Pagoda structures

Like neighbouring Thailand and Laos, the state religion in Cambodia is Theravada Buddhism and over 95% of the population are Buddhist (National Institute for Statistics 2001). Virtually destroyed under the Pol Pot regime, Buddhism has been rigorously rebuilt over the past two decades almost exclusively through voluntary donations.

The religious structure mirrors the political/administrative structure with representation from local to national levels. At the local level, the structure of the pagoda is comprised of the monks who reside in the pagoda and pagoda-associated volunteers that form the link between the village community and the pagoda. Together, they provide moral and practical leadership to the people and manage the affairs of the pagoda. Pagoda associated volunteers are normally esteemed elder men and women in the village who are willing to devote themselves to the pagoda: achaar are former monks skilled in Buddhist learning; chas tom are respected elders; and pritticaar, translated as "elder teachers", are respected prominent individuals known for their good works (Collins 1998). These pagoda volunteers' practice 5-9 Buddhist precepts, are often educated, and are generally respected and trusted by the community. This is the basis of their moral authority. Achaar have been known to take issues to national levels on behalf of the parish. They gain merit by working for the pagoda, which is highly valued as this can ensure happiness in the next life (ibid). Thus, a tradition of voluntarism exists.

The strength of working with pagoda associated volunteers is that they are not a collection of individuals but belong to the pagoda structure which has institutional capacity as well as strong grassroots networks. Management structures, organisational experience and the ability to mobilise material and human resources is evident through the structure and function of the pagoda committees. The chief monk and chief achaar preside over the pagoda and are responsible for the socio-religious and physical needs of the parish. The pagoda committee, comprising 5-7 achaar,pritticaar and chas tom and the chief monk, manages the pagoda's affairs. Its members are elected every three years. The pagoda committee operates with donations from the people, and is expected to keep accurate and transparent accounts. Numerous religious ceremonies involving the offering of donations provide a regular flow of funds for the pagoda.

A larger pool of people in the parish work voluntarily for the pagoda, often having defined roles such as providing food to the monks, maintaining pagodas, collecting donations and organising ceremonies. Under instruction from the chief monk and pagoda committee, sub-committees can be formed to carry out specific projects and find the necessary resources (Collins 1998). This often concerns the collection of donations and mobilisation of labour for the construction of pagoda buildings. But community development activities, as mentioned, such as building ponds, roads, and schools or managing funeral and rice associations, for example, can also be found (Achmoneit et al 1998).

Establishing community participation

Given these characteristics E&D was interested to work with pagodas to develop effective community participation in health. When pagoda representatives were approached to ascertain their interest in collaborating with the Operational District, they responded favourably, viewing the proposal as an extension of an already established role. Subsequently, a Community Participation Advisory Committee comprising pagoda and official representatives was established at a centrally located pagoda to ensure the process was politically and culturally appropriate. At this point, the Chief monks indicated the need to include the Cham Muslim minority.

KOD has 91 pagodas and 5 mosques covering all 290 villages, providing an existing, effective network for community organisation. Two mechanisms for community participation were created. In line with Ministry of Health guidelines (MoH 2000), Health Centre Management Committees (HCMCs) were established in October 2001 for each health centre. Later, in March 2002, Health Action Groups (HAG) were formed in each pagoda and mosque with responsibility for community-based health activities.

Health Centre Management Committees (HCMC)

The HCMC is a Ministry of Health initiative to provide a mechanism for community co-management at health centres to ensure that the health needs and expectations of the population are met. The role of the HCMC is to: (1) promote accountability, good management and community ownership of facilities; (2) provide a communication channel between the community and the health centre; and (3) allow for the introduction of a user fee system for cost recovery that is transparent and pro poor.

In KOD, the strategy is that HCMCs are comprised of one male and one female representative from each pagoda and mosque plus the commune chief(s) and health centre staff. This means, for example, that a health centre with 5 pagodas and 1 mosque in its catchment area would have a HCMC of 12 community members. Health Centres having only one pagoda for their catchment area appointed two volunteers, one male and female, per village to comprise a HCMC.Community representatives were generally appointed through the pagoda committee and/or Chief Monk of the pagoda. Membership of the HCMCs total 245 members, 31% of whom are women. Initial training on roles and responsibilities was provided to all HCMC members, including health centre staff.

Initially, their role focussed on dissemination of information related to public health services to increase the population's awareness of public health reforms, new services and fee structures, build community confidence and stimulate their involvement in new initiatives.

The HCMCs meet monthly at each Health Centre to discuss matters related to the running of the health centre and service provision, monitor the user fee system, obtain health information for dissemination to the community, and to discuss village health issues and community feedback on the quality of health centre services. The latter was facilitated by the placement of anonymous 'suggestion boxes' at each pagoda and mosque. HCMC members are expected to take these suggestions to meetings for discussion. An E&D staff member attends each HCMC meeting at health centres to support capacity building and facilitate training activities. Additionally, Chiefs of the HCMCs from each health centre meet monthly in the OD. HCMC members receive no remuneration besides reimbursement of transport costs.

The HCMCs also coordinate an Equity Fund that has just been established to cover the cost of user fees at the hospital and health centres for the poorest people in the community. The Equity Fund is to be pagoda-managed and funded by community contributions. The HCMC, in consultation with village chiefs, has identified the poorest people for exemption in accordance with agreed criteria. Currently around 32,000 people (about 16% of the population) have been identified. The HCMCs administer a voucher system for use of facilities by Equity Fund patients and arrange payment to health centres and the referral hospital. Initial capital has been provided through a donor grant[1], which will be replenished by pagodas.

Health Action Groups (HAG)

In March 2002, HAGs were formed in each pagoda and mosque to work as community volunteers at village level. The role of the HAG was distinguished from the specific function of the HCMC though there is significant overlap with the membership of the HCMCs and HAGs. HAGs are to be comprised of the two HCMC members, plus one monk and one nun (or female pritticaar). The main role for the monk is to work at pagoda level and ensure the ongoing support from the pagoda. At mosques the Imam, the 2 HCMC members and 2 additional volunteers make up the HAG. Selection criteria for HAG members were discussed and agreed with Pagoda Chief Monks and Imams and candidates selected through them or pagoda committees in consultation with health and NGO staff. There were a total of 383 HAG members selected over 91 pagodas and 5 mosques, of which 38% were women. After three months of activity, health centre staff recommended, with the support of pagodas and mosques, that village chiefs should join the HAGs to lend their authority at village level. Many were already involved in health activities through their official responsibilities but without formal recognition, causing some discontent. The addition of 290 village chiefs increased the total number to 673 HAG members.

Initially, the role of the HAGs was to disseminate health information and encourage better utilization of free, preventative healthcare services. Two community health activities were then initiated. First, a health education program[2], targeting women of reproductive age, aims to improve health knowledge and behaviours regarding maternal and child health. HAG members use picture-based materials to provide community health education to caretakers assembled at the outreach activity. Topics include antenatal care and delivery, breastfeeding and complementary feeding, diarrhoea and hygiene, vaccinations, and birth spacing.