Newsletter – Column H
Rural China Realities (Determination Delivers) -
Bazhong Rural Health Improvement Project1
Village Health Small Grants Scheme
The Bazhong Rural Health Improvement Project (BZRHIP) is a five year (2001 – 2006) development assistance program sponsored by the Australian Government through its international aid agency AusAID. The project works in all four counties of Bazhong Prefecture2 and the goal is to alleviate poverty by improving the health of the rural poor. One of the four Project components is health promotion and this aims to increase health knowledge and positively change attitudes and behaviours in poor rural communities.
The Baseline HESKAP survey conducted in 2001 highlighted the difficulties facing communities. Most villages have just enough land to produce food for small families and a mean annual income of RMB 768 (AUD 124), which is significantly lower than the national rural mean annual income of RMB 1,968 (AUD 318). Hilly and mountainous terrain makes access to townships and essential services difficult. Infectious diseases are the leading cause of morbidity; respiratory diseases 41% and gastrointestinal related 27%.
The BZRHIP health promotion component is supported by a Village Health Small Grants Scheme (VHSGS). The aim of the VHSGS is to demonstrate participatory and inclusive approaches to planning and management in poor rural villages. This approach has been shown to facilitate equitable identification of key health problems and enable design of appropriate and acceptable responses.
Development of the VHSGS within the context of Chinese culture and a resource poor environment presented a broad range of ‘opportunities and challenges’. Major challenges were equitable selection of villages and use of a true participatory approach by government agencies and villagers themselves.
The Chinese Yi Chi tradition, where high levels of personal loyalty are expected, presented a sensitive context within which to develop an equitable approach. Considerable pressure was placed on project staff to select villages that had counterpart family connections. To minimize the negative impact on team relationships and select villages in an equitable way, a set of poverty criteria were negotiated and developed in consultation with all stakeholders. This was a challenging task requiring many hours of discussion to ensure acceptance by the whole project team of this part of the VHSGS process.
At project commencement the general approach of government poverty alleviation agencies was for the decision on what village communities needed, and how these needs would be implemented, to be made by the agencies themselves. For example, how small scale infrastructure projects such as roads, water supplies and the like would be carried out.
Community participation in planning processes at village level is also limited. Although the majority of villagers attend meetings, only village leaders speak. A further dimension is that planning and management of village communities is accepted as a male responsibility with little or no involvement of women.
To ensure participation of all villagers in decision making processes, a series of capacity building workshops with village communities were facilitated over several months. These workshops included involvement of representatives from the All China Women’s Federation (ACWF) and the Poverty Alleviation Development Office (PADO).
Overcoming existing village disputes, low levels of literacy and scepticism from a history of unfulfilled government funding promises was resource intensive, requiring significantly more village visits than initially planned. Implementation processes were reviewed and redesigned enabling an appropriate level of support to be given to each participating village. Building the confidence of village communities in the VHSGS process and the development of trust between village communities and the project were very important steps in creating a positive environment in which to progress the program.
Village remoteness and poor road and weather conditions also required that village visits could be reorganized without negatively impacting on the overall progress of each village project. Time and local knowledge were invaluable resources in being able to effectively progress this part of the VHSGS process.
Local government officials and PADO representatives agreed to be involved throughout the process as observers rather than active participants to minimize the influence of leaders in decision making and begin the process of village community empowerment. Initial defensive reactions to a loss of authority were diffused by working in a supportive and respectful way and inviting them to accompany project staff to each village throughout the implementation process. Government agency representatives’ knowledge and experience on local issues was always sought and respected and progress regularly reported to County and Prefecture levels. Communication between village communities, government officials and PADO departments was encouraged and supported
Fund administration was another challenge. Limited funding for small scale village infrastructure projects is provided by the Province. Decisions on allocation of these funds are made by Prefecture level departments while management of funds is the responsibility of the County. Each administrative level deducts a percentage of the initial allocated funding resulting in only a proportion of the original funding reaching the village.
The BZRHIP VHSGS administers funding dire ctly to village communities in 3 tranches. The first tranche of 60% is distributed at the beginning of the implementation process with the second tranche of 35% being distributed on a satisfactory mid year review of village projects. A bonus tranche of 5% is paid on satisfactory completion and maintenance of each village project.
To ensure proper use of the funds required a systematic, consistent and transparent approach. This included handing over funds at village community meetings to negate the culturally ingrained expectations of personal financial gain to officials and village leaders. Systematic procedures and the transparency of the VHSGS program maintained village confidence and enabled any challenges to the process to be dealt with in a professional and positive way.
Sustainable health promotion outcomes, strengthening of community action, development of personal skills and the creation of supportive environments for positive behaviour change have evolved from building an effective working relationship with PADO, providing an opportunity for village communities to be self determining and openly addresses issues of gender inequity and nepotism.
The VHSGS participatory planning and management approach provided a framework for progressive involvement of PADO. The positive physical and social impacts of the VHSGS first and second rounds was acknowledged by PADO in 2004. A successful combined BZRHIP and PADO VHSGS expansion has been negotiated for implementation in a further 10 villages throughout 2005. The VHSGS participatory planning and management approach will be utilized for the implementation of the expansion, with funding requirements shared equally between the BZRHIP and PADO.
Patience, good negotiating skills, clearly defined principles and an all inclusive approach have changed attitudes and practices of PADO and the government agencies that support them.
The VHSGS has strengthened community action, developed personal skills and created supportive environments. Participatory planning and management of the VHSGS has resulted in a sustainable health promotion program with potential for village community health improvement.
Mary McCabe
Health Promotion Advisor
Bazhong Rural Health Improvement Project, Sichuan Province
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