Tackling social determinants of health through community based initiatives

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 children10^–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.

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

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.