0Tensions Between Community-based and Community-owned
Editorial
For the health programs as well as the research that informs these programs, the culture of verticality has emerged as a serious stumbling block in the path of real empowerment for the most important stakeholders -people. In the programs, this infringes upon the guiding doctrine of primary care, and in research, this hugely tilts the balance of enquiry in favor of "etic," at the cost of "emic" perspective.(1) Because of changing political milieu worldwide as a cumulative effect of historical struggles by ordinary people, "community-based" has been the buzz word for most of the interventions and enquiries during the last two decades. However, the inherent verticality of culture, structure, and governance has reduced this apparently progressive word into a somewhat amusing deduction-"We are here! Will do good to you! And what is good for you will be decided by us!" In India, the strengthening of Panchayat Raj Institutions and the recent interventions through National Rural Health Mission are moves in right direction, but considering the Alma Ata Declaration in 1978, it is too little, too late. Community-based is fine but what if it is tightly choreographed? There is a need to evolve the concept further to emancipate the idea behind it.
Historically, we have made a lot of headway from being merely community aware to community oriented. Now, with the operational locus also shifting to the community and researchers and managers feeling the pressure to make them look community-based, the time has come to identify and analyze the tensions between the contemporary practice and the futuristic move toward community-owned development. The cardinal tension is because of "beneficiary" and "client" centric approaches not paving way to "partner" centric approach. This stagnation fosters a concept of "transformation" forced and sustained by researchers or top-down programs, while the community-owned projects would seek "emergence" with equal partnership. The contemporary environment of protection through research and program ethics, with all its sincerity of intent, betrays a relationship of patrons and subjects of health research and interventions. Meaningful empowerment, on the other arm, demands self-reliance of the community in decision making on research, programs, and their implementation. In the contemporary scenario of health-related
enquiries, even the namesake elements of "respondent validation" are hardly seen, and this "evidence-base" gets translated to policies and programs.
Sometimes, we may start believing that truly community-owned program is a romantic idea of endless activism, and is unachievable, but the global map is punctuated with successful experiences in history and modern times that have had large components of ownership by community. In India, numerous such experiences can be listed, representing widely diverse people, regions, settings, and goals. Systematic and sustained anti-hooch campaigns by women of Uttarakhand and Andhra Pradesh; program against domestic violence by women of Bundelkhand; environment protection in several parts of Himalayan forests and villages; neighborhood cleanliness and hygiene drives conducted traditionally by the Khasi tribes in Meghalaya; and the decades of work in community-owned initiatives coordinated by Vivekananda Girijana Kalyana Kendra (VGKK) in Karnataka, Tamil Nadu, Andaman and Nicobar, and Arunachal Pradesh are only a few of the positive stories to document. VGKK needs a special mention here, for the organization has always been presided and lead by a tribal and aims to provide healthcare, education, and livelihoods to people through their self-reliance.(2) In the area of patient care, North Kerala has built a good neighborhood network for palliative care. Covering a population of over 12 million, this may perhaps be the largest community-owned palliative care initiative in the world.(3) Although modest in terms of scale and longevity, most of these stories are full of promises and possibilities. International actors may be having some stake or interest in some of these community-owned programs, but most of them are indigenous, and could achieve what they did without any substantive presence of aid agencies or foreign universities. On the flipside, their scientific narrative in published space is grossly inadequate. May be, we all are to be blamed for this.
It is not that the future pathways for the state are free of riddles and dilemma. Their actors are also caught in the cleft. Accused of being totalitarian or vertical, when they talk about public-private partnership (PPP), it is seen as an abdication of responsibility. However, the state will have no other way but to blame itself if it allows PPP to be used as parking space for big-time commercial interests. The history of corporate social responsibility
Indian Journal of Community Medicine/Vol 36/Issue 1/January 2011
Chaturvedi: Community-based and community-owned
in our country has little to showcase and is full of bitter lessons. A large section of the sprawling industry of cutting-edge tertiary care and medical tourism under the garb of "research centres" and "health care" is cannibalizing public money for private profit. Local community is seen as an outsider, and outsiders are treated as guests. The moment you enter these centers, you are hit by hard evidence for Two-Nation Theory in healthcare -even though it does not exist in policy. On another related front, the market of most of the health-compromising products is community-based, but the profit is not community-owned, and the PPP runs a huge risk of its land being grabbed by such interests as well. To qualify for community-owned ventures, the community actors should also be active in planning, developing, and decision making about actions for change - a change that emerges through equity and ownership. Equity, in its true sense, comes very slowly for the weak and voiceless. Constitutional protectionism is fine, but the people should now demand for cultural and intellectual equity.
Sanjay Chaturvedi
Professor of Community Medicine, University College of Medical Sciences, Delhi.
E-mail: cvsanjay@hotmail.com
References
1. Harris M. History and significance of the emic/etic distinction. Annual Rev Anthropol 1976;5:329-50.
2. Vivekananda Girijana Kalyana Kendra. Available from: http://www. vgkk.org/wiki/index.php/Main_Pige [Last cited 2010 Dec 27].
3. Kumar SK. Kerala, India: A regional community-based palliative care model. J Pain Symptom Manage 2007;33:623-7.
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Indian Journal of Community Medicine/Vol 36/Issue 1/January 2011
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