CONFLICT BETWEEN TOP-DOWN AND BOTTOM-UP APPROACHES and
WOMEN & COMMUNITIES ARE NOT EMPOWERED TO MAKE DECISIONS
Health planners often work from different basic views and approaches. Three such approaches, as described by Rifkin, are the medical approach, the health planning approach, and the community development approach:
the medical approach sees health as the absence of disease brought about by the modern technology of medical interventions and views the role of the community as responding to directions given by the medical professionals; the health planning approach views health as the result of the appropriate delivery of health service. It argues that medical advances must be integrated into a health care delivery system that includes community involvement; and
the community development approach defines health in the context of promoting better living conditions and integrated development. It is not solely concerned with delivery of health services and believes that community health can begin with non-health interventions. It has been called people centered rather than project centered.
Rifkin suggests how the logic of the approach adopted dictates the way in which planners respond to health issues and how they design projects and programs. Conflicts often occur between top-down health planning and bottom-up community development when these approaches operate simultaneously. However, an understanding and respect for the comparative advantages of each approach can promote a coherent integration of the health system.
The Thiés Child Survival Project in Senegal (see Box 6) is a good example of how one project was perceived by each partner agency from a different perspective, but how the conceptual framework of systems development was used to provide a coherent integration strategy to avoid top-down and bottom-up conflicts.
The Thiés project also demonstrates that while International Private Voluntary Organizations (PVOs), such as World Vision, CARE International, Africare, and Save the Children Federation have become recognized experts in using the community development approach, they do not have much experience or expertise in interfacing community development with an integrated health system.
Given the interest by A.I.D. in working more closely with NGOs and PVOs, it is important to recognize that just as they had to learn how to design, implement and evaluate PVO Child Survival grants, they will also need to learn how to work effectively in systems strengthening.
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Box 6 THE THIES CHILD SURVIVAL PROJECT, SENEGAL The Thiés Child Survival Project (TCSP) demonstrates how one project can be perceived by each partner agency from a different perspective, but how the conceptual framework of systems development was used to provide a coherent integration strategy to avoid top-down and bottom-up conflicts. In April 1991, A.I.D. provided a child survival grant to World Vision Relief & Development for the Thiés Child Survival Project in the health district of Mekhé, Senegal. The mid-term project evaluation noted the partner agency perspectives: AID /W viewed TCSP primarily as a project to promote cost-effective child survival interventions including immunizations, oral rehydration therapy (ORT), prenatal care, growth monitoring and family planning, i.e., a selective primary health care approach to integration. Project interventions, such as training, health management information system (HMIS), and cost recovery, are also emphasized to strengthen the support systems related to those interventions. World Vision viewed TCSP primarily as a project to promote integrated development at the community level, i.e., a bottom-up strategy for health development. TCSP was only one component of World Vision's Integrated Rural Development Program which included water development, agriculture, primary health care,, social mobilization, education and Women in Development. The Ministry of Health viewed TCSP primarily as a project to implement the national strategy to promote decentralization and organization of primary health care at the health district level. In collaboration with the World Bank, five-year detailed implementation plains had been established for each health district, i.e., a top-down development strategy. The MOH wanted TCSP to assist the health district in the implementation of that plan. While these different views could have resulted in considerable conflict in how TCSP was managed, or what activities were emphasized, the evaluation found that all the partners involved were in agreement to complement each other's comparative advantage to build and integrated health system. However, the evaluation also noted that the existing weak management capacity of the health district team coupled with the inexperience of World Vision in systems strengthening of health districts, required some major changes in project implementation. |