February 2013, Volume 63, Issue 2

Original Article

Governance in community based health programmes in I.R of Iran

Katayoun Falahat  ( Undersecretary for Research and Technology, Ministry of Health and Medical Education, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran. )
Monir Baradaran Eftekhari  ( Undersecretary for Research and Technology, Ministry of Health and Medical Education, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran. )
Hossein Malekafzali  ( Department of Epidemiology and Biostatistics, School of Public Health , Tehran University of Medical Sciences, Tehran, Iran. )
Ameneh Setareh Forouzan  ( Social Determinant of Health Research Centre, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran. )
Masoumeh Dejman  ( Social Determinant of Health Research Centre, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran. )

Introduction

The World Health Organisation giving strategic prominence to its 2008 Alma-Ata declaration has again emphasised the element of participation and has requested all its members to make available a suitable environment for community participation in health-related subjects. As defined by the WHO, participation is a process whereby community members collectively assess their health needs and problems and organise to develop strategies for implementing, maintaining and monitoring solutions.1 In other words, the working definition of community participation is described as a process by which people are enabled to become actively and genuinely involved in defining the issues that are of concern to them, in making decisions about factors that affect their lives, in formulating and implementing policies, in planning, developing and delivering services and in taking action to achieve change.2 The rationale for pursuing community participation consists of promoting positive health behavioural change; developing service delivery; mobilising resources for health services; and empowering the community.3
There is increasing evidence that consumer and community participation can improve health outcomes, lead to more responsive care, facilitate people\\\'s involvement in treatment decisions and improve quality and safety. Besides, it can help to reduce political risk, encourage clinical accountability, identify workforce issues and foster more responsive and equitable services.
In addition, it encourages better utilisation of health services by discouraging health-harming behaviour and changing expectations about the role of health staff and health services.4
In the Iranian context, since 1990, different community-based programmes have been implemented by governmental and non-governmental organisations in different fields of health. To the best of our knowledge, few national cross-sectional analyses of these community-based health programmes (CBHP) have been done. The main study sought to ask service users and programmes managers as well as volunteers about their experiences conducting CBHP in Iran. The goal of the overall study was to understand the nature of CBHP practice in Iran and use the data to advocate CBHP-friendly policies in the community, academy and funding organisations. In this article, we present the broad range of experience of those engaged with CBHPs in Iran regarding issues related to governance.

Subjects and Methods

The qualitative study was conducted in 2010-2011. This is a proven method for gaining insight into the participants\\\' experiences.5 Individual interviews were conducted with principal and executive managers to understand their point of view and experiences.6 Focus group discussions were conducted with volunteers and service users because of their usefulness in understanding group opinions, concerns, attitudes and experiences.7
The study protocol was approved by Ethical Committee of the University of Social Welfare and Rehabilitation Sciences. An advisory committee was formed to supervise the study, comprising CBHP managers, researchers, WHO representatives in Iran and a number of programme managers from the Ministry of Health and Medical Education (MOHME). The members were recruited based on their knowledge and expertise in various areas of CBHP.
A total of 13 CBHPs (Table)

were chosen by the advisory committee. The selection of the programmes was based on two-tier inclusion criteria: They needed to be active over the proceeding five years; and to have basic CBHP characteristic. The programmes were selected from both governmental and non-governmental sectors.
Based on their collective experiences and a thorough literature review, three question guides for interviewing programme principals and executive managers, volunteers and service users were developed. Guide questions consisted of five themes, including stewardship; participation; collaboration with other organizations; programme monitoring and evaluation; and resource mobilisation. The applicability of the guide questions were confirmed by the advisory committee and research team through a pilot study. Subsequently, the main phase was initiated.
The participants were purposively (6) selected from each programme with the assistance of key persons who were familiar with and involved in the programme for a long time. For each programme, two interviews with the principal and the executive manger, and two group discussions with volunteers and service recipients (20 group discussion, totally 102 people) were conducted. The focus groups were made up both of men and women, and each group had 5-8 participants. A total of 21 interviews were conducted, while there were 20 focus group discussions (FGDs) involving 102 people.
The research team constituted of six individuals who were completely familiar with qualitative research and interview methods. In a 4-hour session, the study objectives and question guides were explained and probable problems which might be incurred during the implementing phase were described. For each interview, the moderator/interviewer started the interviews by explaining the nature and purpose of the study before obtaining informed written consent. Permission to audiotape the interview session was sought orally prior to the interviews. The participants were also informed about confidentiality, that the participation was voluntary, and they were informed of their right to withdraw from the study at any time during the interview.
After the introduction, the moderator/interviewer gave an explanation about community health participation and then asked about the components of CBHP. The participants were encouraged to talk openly about their experiences relating to the programmes. Probes were used to confirm understanding of the concepts, and to explore areas that the participants did not discuss spontaneously. The researchers took field notes immediately after each interview. Each individual interview lasted 1-1.5 hours and each FGD lasted 1.5-2 hours, and ended when no new issues seemed to arise. The whole process of sampling and collecting data lasted five months, from August to December 2010. Some of the interviews were not fully completed due to the non-cooperation of the respondents.
Data analysis was based on deductive-inductive content analysis approach.8 The structure of the analysis was based on previous knowledge and the purpose of the study.9 Analysis started from each interview, which was transcribed and analysed both manually and with the aid of open code 3.4 software. The transcripts were read with the intention of deriving \\\'meaning units\\\' (covering words, phrases and/or paragraphs).10 Then the codes and categories were compared in each programme to get a whole picture of the programme. The coding scheme was derived theoretically according to the components of the CBHPs.11 The inductive codes were sorted into meaningful clusters to describe a CBHP.12 Then the codes were compared between the programmes to create broader categories that linked codes across interviews. Common classes were merged and conceptual classification was based on leadership and participation concepts. This paper presents the findings related to the concept of leadership.
In order to increase the reliably of data, all codes and classes were cross-checked by the advisory committee. We shared summarised interview findings with relevant people to address issues of respondent validation.13 To assess dependability, peer-checking by experienced colleagues to re-analyse some of the data was performed. Consistency checks between colleagues were also performed throughout the coding process for team consistency.14

Results

The average age of volunteers who participated in the study was 35±7 years and their range of education varied from simple guidance to above high school diploma. Among the recipients, the average age was 37±10 years and the education ranged from primary school to high school diploma. Interviewing with principals was implemented completely, and with the executive manager only at the level of the Primary Healthcare Network programme. The participants\\\' views were analysed within the main category of governance, including the three subcategories of leadership, monitoring and evaluation, and resource mobilisation.
Leadership mainly focused on selection of project manager and decision-making process. According to the participants, governmental programmes have centralised decision-making and management processes and local volunteers have no role in selecting managers or administrators at different levels of the programme such as executive managers. However, in Healthy City and Healthy Village, Municipality Health Houses and Population Research Station programmes, volunteers actively participated in the selection of the cluster-head and health committee members and participated at the general assembly meetings at district levels. In NGO programmes, the board of trustees is responsible for selecting the board of directors, which, in turn, selects the managing director. All decisions are made by the board of directors and disseminated for implementation throughout the organisations through different forms of directives or information circulars. Most health promotion community-based activities are designed and implemented at the national level and are highly supported by organisations. Community-based interventions are designed at the level of districts (local communities) rarely. Axes of intervention consisted of various spectrum of health problems in individual, environmental and social aspects in the participating programmes. The aim of these interventions was promotion of health community and quality of life at local, provincial and national levels using people participation and inter-sectional cooperation. These interventions caused different degrees of empowering in community and concerned organisations. Totally, all the assessed programmes were community-based. It seems that interventions were institution based, not community-based in most of these programmes.
In governmental organisations such as MOHME, municipalities and social welfare organisations, programmes budget is funded by the governmental core resources. In programmes such as Laborious Health Houses, the employer (under whose control these houses are located) is committed to pay salaries and provide services or in-kind benefits. However, the costs for day to day operating or service delivery of such facilities are usually supported by charitable organisations such as the local municipalities or individuals. In non-government organisations, resources available for such purposes are mainly given through charitable individuals, service delivery fees and profitable activities, financial participation of volunteers, and using of other organisations\\\' facilities.
In terms of evaluation and monitoring, some programmes affiliated with MOHME are monitored through field visits with standard checklists and assessment of the monthly reports. Most of this monitoring was without any feedback.
Some programmes such as the Women Health Volunteers and Community-Based Rehabilitation, were evaluated internally, but the results were not published. The Municipality Health Houses programme is the only programme with continuous and organised monitoring, as well as internal and external evaluations system. Also, Safe Society, Healthy Village and Healthy City programmes have been evaluated once. The overall objective of the Healthy Village and Healthy City programmes evaluation was to assess the inputs, the process, outputs and impact of such programmes in Iran, aiming at reviewing the implementation, methodologies and process for further expansion and institutionalisation in the health and development sector. The main objective of Safe Society evaluation where the community was involved, was to determine the degree to which the \\\'Safe Society\\\' model is effective in reducing injuries in Iran. In most of the CBHPs, there were no systematic process for monitoring and evaluation. In non-government organisations, there is no organised system or process in place to evaluate the programmes, and activities are monitored by assessing the reports by the board of trustees. One of the most important challenges of CBHP articulated by most of the participants was lack of structure for evaluation and feedback from the community.

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