BMJ  2006;333:854-856 (21 October), doi:10.1136/bmj.38988.607836.68

Analysis and comment

Tackling social determinants of health through community based initiatives

¹ Community Based Initiative Unit, Eastern Mediterranean Regional Office, World Health Organization, Nasir City 11371, Cairo, Egypt, ² Health Policy and Planning Unit, Eastern Mediterranean Regional Office

Women are often the key to improving a population's health, and this is especially true in the Eastern Mediterranean region. Projects that empower women and provide basic needs are transforming poor communities

Many of the inequalities in health, both within and between countries, are due to inequalities in the social conditions in which people live and work.¹ These social determinants have a important effect on health status and general wellbeing. Tackling these underlying causes of poor health can contribute to improving health and health equity.² The World Health Organization has given this approach added impetus by the creation of the Commission on Social Determinants of Health. Over the past two decades the basic development needs programme, a component of the community based initiatives programme in the WHO Eastern Mediterranean region, has developed and implemented community based initiatives to improve health in poor populations through actions on social determinants. The basic needs development programmes, which enhance the status of women and their role in the health of families, are an important part of this work.

Gender and health

The low status of women in the Eastern Mediterranean region is one of the key underlying social determinants of health. Sex differences in access to health care and poor health indicators for women and girls in several countries have resulted in differences in mortality and morbidity between male and female infants,³ differences in the quality of care for male and female children,⁴ high maternal mortality (estimated at 1600 deaths per 100 000 live births in Afghanistan and Somalia),⁵ limited prenatal and postnatal care and lack of skilled attendants at birth,⁶ higher prevalence of mental illness among women than men,^{7 8} and high rates of suicide and attempted suicide among women of reproductive age.⁹

Gender determinants that have an adverse effect on the health of girls and women include low valuation of girls compared with boys and of women compared with men; social structure and beliefs that tolerate violence against women and children^10-12; limited autonomy for women in making choices about treatment for their children or themselves¹³; and considerations of family honour that are associated with early marriage for girls and female genital mutilation.^{14 15}

Basic development needs programmes

The basic development needs programmes help to enable women by giving them the opportunity to earn money through loans and training. The programmes also include measures to improve health and wellbeing such as health services, nutrition, safe water, sanitation, and shelter. The first programme was initiated in Somalia in 1988, and the model has been extended to support community development in 12 countries in the WHO Eastern Mediterranean region: Afghanistan, Djibouti, Egypt, Iran, Iraq, Lebanon, Morocco, Oman, Pakistan, Somalia, Sudan, and Yemen. Programmes now cover a population of almost three million in over 250 sites.

The programmes strongly emphasise community involvement and intersectoral collaboration, facilitated by WHO linkages with ministries of health (see bmj.com). Intersectoral coordination encourages government departments to work together, mobilises communities, and involves them in the development process. Intervention sites are identified in response to a request from the local residents. Each village is divided into clusters of 25 to 40 households. Each cluster elects one representative. The cluster representatives then nominate a village development committee. An intersectoral technical team provides training and back-up support and helps conduct a baseline survey. Each household is asked to identify their top three social development priorities. The final interventions are decided by the community on a consensus basis.

Rubbish disposal initiative in Djibouti

 

WHO has a catalytic role, providing soft loans against small scale income generating projects and for social uplift projects such as water supply and sanitation. The loans are usually $10 000-$50 000 (£5000-£30 000; 8000-40 000) for each site, to which the community contributes 25%, and WHO supports about 25 new sites annually. The beneficiaries of the loan contribute 5% towards a community development fund that promotes health, social, and environmental activities in the village. Loans are returned in monthly installments once the project has reached maturation. The default rate is below 10%. The amount returned is retained within the community as a revolving fund. Local non-governmental and community based organisations also fund projects using this approach.

Effect of basic development needs programmes

The experiences of two villages, Dar Mali in Atbara State, Sudan, and Gallamo in Djibouti show how the villagers have been able to bring about the change through simple community based interventions (box and bmj.com).^{16 17}

Programmes have been evaluated in Djibouti, Pakistan, Sudan, Yemen, and Iran.^{18 19} These show that the literacy and vocational training centres for women contribute to improvements in maternal care, family planning, and immunisation coverage for children (see bmj.com). Formal and community evaluations have identified several strengths of the programmes including well organised, aware, and enthusiastic communities; active participation of women in income generating activities; empowered communities that feel confident in approaching local governments and other agencies for new projects; and better health coverage indicators. Neighbouring communities have also been encouraged to organise themselves and make efforts to raise funds for social development projects.

Basic development needs programme in Dar Mali, Sudan16 The village has a population of over 2000 and the programme was started in 1998. Since then the community has: Constructed a safe drinking water supply to cover the whole village Developed a rubbish disposal system using local resources such as donkey carts Established a community based health information system, which collects and analyses data and facilitates planning and management of health and development programmes Rehabilitated the secondary school, obtaining $134 000 from the state government to construct new classrooms, establish a laboratory, and buy chairs and desks Established a youth development centre with $10 000 from the government At present 285 small income generating initiatives are being implemented in the village. Poor members of the community have been provided with impregnated bed nets for prevention of malaria. Female cluster representatives have been trained on maternal and child care and are actively promoting health and educational activities.

Challenges and opportunities

The two major challenges for these programmes are sustainability of the existing projects and scaling them up to national level. War and civil strife have prevented the governments in Afghanistan, Iraq, and Somalia from providing effective support for the programme. In Lebanon, the programme relies on nongovernmental organisations, and government involvement has been minimal.

The programmes cannot be sustained without the support of local governments and civil society. Governments in Iran and Pakistan have provided this support. For example, in February 2006 Sindh Department of Health approved a programme of over $400 000 covering four districts in the Pakistani province.²⁰ Several districts in the country have independently come up with their own projects, which are incorporated into the local district structure. Using the mechanism for community action, the Global Fund to Fight AIDS, Tuberculosis, and Malaria provided $2.7m for fighting malaria and tuberculosis through the basic development needs programme in seven districts for 2005-6.²¹

Summary points Basic development needs programmes are community based initiatives that can tackle poverty, ill health, and social determents of health Enhancing the status of women is of special relevance for programmes in the Eastern Mediterranean region Programmes enable women to earn money and improve their access to basic physical, health, and social needs National and local government commitment and collaboration with civil society are essential to scaling up these programmes

Sustaining community based initiatives

Commitment of national and local governments, collaboration with civil society, and some form of external financial support are essential to maintain and expand these community based initiatives. Monitoring, evaluation, and documentation need to be improved to inform their further development. But care should be taken that data collection and management does not compromise the participation of community members. A feeling of ownership is essential.

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Further information on basic development needs programme is on bmj.com

Contributors and sources: All authors discussed the concept and formulation of the paper and went through the revisions. SW wrote the first draft and provided literature from the region on social determinants, MA provided basic information on the work of community based initiatives in the region, SS provided the initial conceptualisation and developed the subsequent versions. MA has been working in the area of community based initiatives since 2000; SS is the regional focal person responsible for the social determinants of health; SW is a social scientist with several years of experience in the region.

Competing interests: None declared.

References

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21. Global Fund to Fight AIDS, Tuberculosis, and Malaria. Application form for the proposal to Global Fund. CCM Pakistan proposal round three. Geneva, 2003. www.theglobalfund.org/search/docs/3PKSM_698_0_full.pdf (accessed 28 Sep 2006).

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