Community based programs are public Health interventions that are designed, implemented and evaluated with the participation of the community representatives and with the guidance of professional experts. In Nigeria, after the acceptance of PHC in the national health policy, different community based health programs has been initiated. Among these, the use of community health Extension workers and the new Health service extension package are discussed.

At the end of this page, you should be able to:

 Describe the responsibility of the community in the health care system.

 Describe the community involvement in the health delivery system

 Define the concept of the health care team.

 Describe the need for team based health care and role of the health service team leader.

Definition of community Based Health Service

Community Based Health Service is a package of services that includes provision of immunization, prevention, control and treatment of malaria, prevention of HIV/AIDS/STDs, tuberculosis, provision of oral contraceptives, deliveries, follow up of high risk pregnant mothers, first aid, sanitation services including excreta disposal, insect and rodent control, safe water supply, housing construction and overall environmental issues in the rural context. It is to improve access and equity to preventive essential health intervention through community based health services with strong focus on sustained preventive health actions and increased health awareness.

Community Health Extension Workers

The concept of the community health Extension worker (CHEW) has found new expression in health programs in many parts of the world as part of the Primary Health Care initiative springing from Alma-Ata. It is an adoption of traditional village practice of midwives and healers to modern, organized public health services. CHEWs were first recruited to provide care in rural areas in developing countries without access to health care. They are selected from the community and training will be given by the Ministry of Health (health centers).

Community health Extension workers may provide services on categorical target diseases. These include malaria control, tuberculosis directly observed therapy (DOT, providing medication under supervision to assure compliance), support services and counseling for multiproblem families in an inner-city poverty area, STD follow-up, and promotion of immunization Health Service Extension Package (HSEP)

The main objective of HSEP is to improve access and equity to preventive essential health intervention through community based health services with strong focus on sustained preventive health actions and increased health awareness. The health extension service is being provided as a package focusing on preventive health measures targeting households particularly women/mothers at the rural level.

Community responsibility

Need, demand, custom and general development have led society to accept certain health services as a community responsibility on behalf of the total citizens. As the population increases and tends to concentrate in urban centers, some new health problems that have long been with communities become more complex and more difficult to manage. If community health problems of today are more complex, society has advanced technology in dealing with some of them. Most community health services directly or indirectly will be of value to all citizens but of greater value to lower income group than to higher economic groups. For instance, community immunization services will have a greater protective impact on lower income groups but will have some value, direct or indirect, for people on all income levels.

Community involvement in health (CIH)

The idea of community involvement in health (CIH) emerged as a result of concern to encourage local participation in all aspects of development, including health development. It means local participation in the design and delivery of health care services. In most areas of development, preference seems to be given to the term community participation‘because of its deeper implications.

Community participation: There are a Varity of different interpretation of the concept of participation. It is important to reduce the different views of concept of participation by distinguishing two broad, but very different categories of interpretations as the two ends of a continuum: participation as a means and participation as an end.

Participation as a means: Health development is an important element in the development process in general and is therefore influenced in practice by different perceptions of what constitutes development and what causes under development. Until recently, early 1970s, the development process was largely dominated by attempts on the part of development planners and workers to modernize and improve the technical performance of the physical assets of a particular country or area. But starting from the early 1970s, a fundamental reappraisal of the nature and content of the development process has been underway. The essential feature of this appraisal has been the concept of participation. In this interpretation, participation is seen as the means of achieving a set of objectives or goals. Government and development agencies responsible for providing services and with the power to control resources see participation as a means of improving the efficiency of their service delivery systems. Sharing in the benefits of the delivery system is the more characteristic outcome of this form of participation. It is the form of participation more commonly found in rural development programmers and projects.

Participation as an end: Participation in rural development may on the other hand be regarded as an end in itself. In a rural development project, participation as a process is a dynamic un-quantifiable and essentially unpredictable element. It is an active form of participation, responding to local needs and changing circumstances. Generally, participation as an end in itself presupposes the building-up of influence or involvement from the bottom upwards. As a result, this form of participation has come to be associated with development activities along with the formal government sector, and is concerned with building up pressures from below in order to bring about change in existing institutional arrangements.

Team Approach in Health Service
Need for the Health service team.

In order to effectively respond to identified needs, health persons must be able to work within a team framework in which problem solving is approached in an integrated manner. A health team must be in a position to effectively communicate information to communities and individuals and develop mechanisms, which facilitate their involvement in all health activities. A health team must also establish communication links with other sectors and promote intersectoral collaboration. The need for a better-integrated health care team occurs because of:

 Poor communication: -Lack of integrated record keeping system result in an uneven and incomplete exchange of information among the professionals who provide health care services.

 Duplications of services: Lack of coordination and communication at times leads to duplication of services. For instance, if service provider does not have access to test results previously ordered, a request will be made for new test. Diagnostic tests and other services may be repeated by several service provides, resulting in excess cost and additional stress for the patient. Errors and inappropriate therapy from prescription of medication may occur when more than one health professional are prescribing drugs for a patient.

 Lack of patient focus: Patients are seeking continuity and coordination of care, competence, accessibility and timeliness, reasonable cost and some sense that someone in the ―system‖ cares about them. When health care professionals do not work well together, patients feel that commitment to them as individuals in need of care is lost.

The Health Team

The health team may be defined as a group of people who share a common health goal and common objectives, determined by community needs, to the achievement of which each member of the team contributes, in accordance with his/her competence and skill and in coordination with the functions of others. All personnel working in the primary health care post, sub-center or center constitute the health team. The term does not refer only to the personnel concerned with the health care directly, such as medical officers, nurses, auxiliary nurses, midwives, sanitarians, and traditional or trained birth attendants, but also comprises of health care workers as well as other supporting personnel including, divers, clerks, storekeepers and other persons working in the health institution.

Competence of health care team

No one model is appropriate for the variety of settings in which team delivered health care operates. Membership of the team, and issues such as distribution of authority and communication mechanisms will vary widely depending on the purpose of the teams; whether the team is community based . . . delivering services to a home care population; or clinic based . . . providing services to individuals with severe chronic diseases; or hospital based . . . furnishing care to the most severely ill, in an intensive care unit. However, the absence of a single model does not mean that good teams share no common attributes.

The following are key characteristics of a well functioning health care team Patient centered focus:

a. A good team must have as its first priority meeting the patient’s need. A team with a patient centered focus will consider and respect the patients values and preferences when making care decisions.

b. Establishment of a common goal: If the patient‘s needs are to be the focus, it is critical that all team members know what a successful outcome for each patient‘s care will be. At times a successful outcome may not be self-evident. For example, health care professionals treating a critically ill patient may work at cross purposes if some feel the patient should be treated aggressively while other feel that the patient should only receive palliative care. Such confusion may be avoided only through an explicit process for goal definition. If choices are to be made between competing outcomes, the patient and/or the patient family must of course be involved.

c. Confidence on other team members: Confidence in other team members develops with time and most certainly requires an understanding of other member‘s roles. Each member must be able to trust the work of others. If professionals do not have trust in another‘s work, duplication of services may occur. For example, a specialist physician who is not confident in the care provided by the general practitioner may order extra or unnecessary test for the patient.

d. Flexibility in Roles: While understanding and respect for each person‘s specific role is important, flexibility in assignments is also important. It is undesirable for each team member to duplicate efforts made by others; but, if meeting the agreed upon objective calls for changes or flexibility in roles, team members must be prepared to act accordingly and with respect to professional standards of practice.

e. Mechanisms for conflict Resolution: Every health care team will experience instances of conflict. However, a successful health care team will identify a specific mechanism, clearly understood by all, for resolving conflict, through a team leader, outside leader, or other process.

f. Development of effective communication: Good health care team communication involves at least two components . . . a shared, efficient and effective reward keeping mechanisms, electronic or other, and a common vocabulary.

g. Shared Responsibility for team Action: Effective team functioning can occur only if each team member shares fully the responsibility for actions of the team as a group . . . and is willing to be held accountable to these actions. Understanding of such responsibility requires of course confidence in the abilities of the other team members, good communication and agreement up on a common goal.

h. Evaluation and Feedback: Team design must be dynamic open for evaluation and revision on a continuing basis. A model that worked previously may no longer be obtained, as there is change in the patient‘s needs, the health care delivery system or the expertise of team members. A specific mechanism must be developed for ongoing evaluation of a team‘s effectiveness and redesign activities where needed.

Leader of the health Team

The health team should have a leader, who should inspire confidence in the community, which needs and seeks medical care. The leader should be able to induce colleagues and team mates to work to the best of their capacity.

Attributes of a Health Team Leader.

i. Co-ordination and co-operation: The team leader should be able to achieve preferred co-ordination and co-operation with all members of the team, so that the efficiency and output of the heath team is high and the work is interesting, satisfying and rewarding. The leader of the health team should realize that the health team consists of individuals who have

feeling, personal interests, stress, conflict, likes and dislikes, just as other people. Health team members appreciate encouragement praise and appreciation for their achievements, from their leader. The emotional needs of people are better satisfied, if they are given the responsibility and authority to carry out the jobs assigned to them.

ii. Approachability: The team leader should be easily approachable, so that the team members can reach him and seek his help and guidance for solutions to their personal, technical and official administrative problems. He should earn respect from his juniors and not command it by creating awe and by his blistering behavior.

iii. Competence: The leader should be competent in his own technical work, so that his teammates respect him for his knowledge and skills.

iv. Disciplined and well organized: The team leader should be disciplined and well organized in his thought and work. He should arrange to disburse the salaries of the staff regularly, procure supplies in time and exude an image of an efficient manager of affairs. This can easily be achieved by delegating responsibilities for simpler tasks to his subordinates.

v. Delegation of authority: The focus of a good team leader should be on setting the job done and not on who does the job. A manager should not overburden himself with routine activities, because he must have time to think, plan and co-ordinate the work of his teammates. Delegation of responsibility and authority by the team leader to the health team is equally important in the primary health care setting. The efficiency of the health care system improves since it saves time of the leader, particularly if the catchment area under him is large.

vi. Supervision of the health team: For accomplishing the desired result, activities of different members of the team need to be co-coordinated. Health team is like a chain; one weak link in the chain breaks the entire chain. A good leader identifies the weak links by constant supervision at regular intervals. The leader of the team should prescribe the proper norms of performance and define the time period during which the specific job should be completed. The workers should be made fully aware of what is expected of them. The supervision should then review their work by analyzing the tasks completed in the given time in relation to the expected quality of work and standard of performance.

vii. Supervisory style: Depending on the nature of the team, the team leader may be an autocrat or a democrat. Authoritative or autocratic and democratic or consultative style of supervision has a distinct place and role in taking management decisions. The autocratic style of supervision is more suitable, when the results proposed to be accomplished have to be consistent and uniform and need to be achieved quickly, such as health problems due to epidemics rages of war and natural disasters. It is good to apply democratic styles of supervision when the colleagues in the team are well educated, competent, reliable and experienced. In a consultative style of supervision, the workers shoulder greater responsibility and give their best to the organization.

viii. Span of control of the supervisor: For the best result, the span of direct control of the supervisor should be restricted to about six to ten persons. But a good manager may be able to extend his supervisory span indirectly by delegating some of his supervisory change to appropriate workers lower in the line of command.

ix. Co-ordination between the team members: the supervisor of the team should ensure that individuals in the health team cooperate with each other and coordinate their activities to   accomplish the desired tasks. Therefore, the first essential work by a supervisor to be communicated in unambiguous terms to the workers is what is to be done, by whom, where, how and when. If the number of people in the team to be coordinated is large, it is useful to convene a meeting of all concerned at a convenient, time acceptable to majority of them. In this meeting, the team leader should sort out difficulties and doubts of the workers and decision should be taken and announced to all members.