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4. Leaders whose first responsibility is to the poor. Programs recognized
as effective usually have leaders who are strongly committed to a just society.
Often they have had intense personal experience working with the poor in
community efforts to help solve critical needs. Even as their programs have
grown and expanded, these program leaders have kept up their close relations
with the poor working people in individual communities.
5. A recognition that good health can only be attained through helping
the poor improve the entire situation in which they live. Successful
programs link health activities with other aspects of social development. Health
is seen as a state of wholeness and well-being in which persons are able to
work together to meet their needs in a self-reliant, responsible way. This means
that to become fully healthy, each person needs a clear understanding of himself
or herself in relation to others and to the factors that influence all people’s well-
being. In many of the most effective health programs, activities that help people
to develop a more critical awareness have become a key part of training and
community work.
In view of these features common to success, the failure of many national and
regional ‘community health’ programs is not surprising. Most are carried out in quite
the opposite way. Although their top planners speak proudly of “decision making
by the community,” seldom do the people have much say about what their health
workers are taught and told to do. ‘Community participation’ too often has come to
mean “getting those people to do what we decide.” Rather than helping the poor
become more self-reliant, many national health and development programs end up
increasing poor people’s dependency on outside services, aid, and authority.
One of the biggest obstacles to ‘health by the people’ has been the unwillingness
of experts, professionals, and health authorities to let go of their control. As a result,
community health workers are made to feel that their first responsibility is to the
health system rather than to the poor. Usually they are taught only a very limited
range of skills. They become the servants or ‘auxiliaries’ to visiting doctors and
nurses, rather than spirited leaders for change. They learn to follow orders and fill
out forms, instead of to take initiative or to help people solve their problems on their
own terms. Such health workers win little respect and have almost no influence on
overall community health. Many of them get discouraged, grow careless, become
corrupt, or quit. Results have been so disappointing that some experts, even
within WHO, have begun to feel that the goal of ‘health for all through community
involvement’ is like the pot of gold at the end of the rainbow—a dream that has
been tried, but failed.