Cím: | Community Health Plan |
Szerző: | Fehér István, Füzesi Zsuzsanna, Ivády Vilmos, Tistyán László |
Sorozatcím: | |
A kiadás helye: | Pécs |
A kiadás éve: | 1999 |
Kiadó: | Soros Alapítvány, Fact Alapítvány |
Terjedelem: | |
Nyelv: | angol |
Tárgyszavak: | település, község, egészség, egészségterv, életminőség, lakókörnyezet |
Állomány: | |
Megjegyzés: |  |
Annotáció: | |
ISBN: | |
ISSN: | |
Raktári jelzet: | E |
COMMUNITY HEALTH PLAN
Written by
István Fehér
Zsuzsanna Füzesi
Vilmos Ivády
László Tistyán
Manuscript read by
Júlia Kishegyi
Translated by
Alan Campbell
Soros Foundation
Hungary
Pécs, 1999
„Health promotion is carried out by and with people, not on or to
people. It improves both the ability of individuals to take action, and
the capacity ofgroups, organisations or communities to influence the
determinants ofhealth."
„Improving the capacity of communities for health promotion requires
practicaleducation, leadership training, andaccess to resources."
extracts irom the Jakarta Declaration
Foreword
"Our understanding of the world in which we live is inherently imperfect and a perfect society is unattainable. We must content ourselves with the second best: an imperfect society that is however, capable of infinite improvement." (Kari Popper)
It was in accordance with this idea that the Hungarian Soros Foundation launched the Community Health Plan programme.
The purpose of the programme presented here is to seek solutions to specific problems in communities, and at the same time to explore the potential application to social problems of an approach which is new to Hungary and to the whole region (Central and Eastern Europe), one grounded in the revival of communities, giving them self-confidence and widening the scope for their own actions.
This is how an Open Society works: through the invisible network of people who feel responsibility for their own community and want to do something, eventually creating a society responsible for its own casualties, sick people - and healthy people.
Anna Belia | Katalin Szőke |
Program Director | Program Coordinator |
What is o health plan?
Before defining what we mean by a health plan (The terms "Community Health Plan" and the idea of producing such plans originates from the Healthy Cities Project of the World Health Organisation. Health profiles and health plans are now produced in many towns throughout Europe. The first town in Hungary to start on preparing a health profile and a health plan was Pecs in 1995, using a method drawn up by the Fact Foundation. Since this first initiative, the process has widened into something ola "movement". There are now more and more broad-based programs in Hungary corresponding to the concept of the health plan. The model and recommendations outlined in this publication have evolved out of several years' experience of developing the original health plan concept into a practical policy.), let us give some thought to the question of why it is important to draw up a health plan.
What is the purpose of the health plan?
In the former socialist countries, drawing up health plans for single towns and villages can serve several purposes:
● First and foremost, to improve local residents' quality of life, and thereby their health.
● To adopt practices for planning and implementing local quality-of-life improvement programmes that:
- involve community members in the process and give them the opportunity to influence and actively support it,
- clear away the remnants of the old paternalistic practices,
-strengthen individual and community autonomy, raise self-confidence and, as a consequence, build a sense of responsibility.
● To raise the chances of resolving problems in reasonable time by involving the community's own intellectual and materia! resources.
● To build the community on the guiding principles of quality of life, and of health.
So, what is a health plan?
It is easiest to answer this in the negative: a health plan does not mean the planning of health services - it both more than that and different from it.
Put positively, the briefesi answer is: a health plan is a broadly-based plan and programme of action for changing living conditions and improving quality of life in a particular community (i.e. town or viliage). A health plan takes on real value and achieves a real chance of success if those affected (the population, NGOs, the local authority and other authorities, the health and education institution, etc.) are involved on equal terms in producing and implementing it.
A health plan is an activity programme expressing the aggregated shared will of the people living in the local community for improving their quality of life, and consequently their health. Put anoth-er way: a health plan is a community-based method of problem-management involving the active participation of those most affected by the problems.
A health plan is therefore the combination of objectives and the methods employed io reach these objectives.
Factors adverse to quality of life iake their toll on both individuals and the community. We can only make some headway against the harmful effects of these factors (unhealthy lifestyle, environmentally polluting practices, etc.) if we can offer models of action acceptable and attractive to both individuals and communities.
The substance and methods oi the health plan
Substance | Methods |
| 1. Addresses health issues from the direction of quality of life. Assesses and improves health not only as physical health, but also, by building a healthy local community, the quality of life of people within it. | 1. Employs a broad-based approach. The health plan extends to all factors
which can affect health. It must therefore include in its scope matters
which do not fit into the traditional health care approach (transport
facilities, feelings of personal security, etc.). Whereas everybody can
participate in improving quality of life (citizens, authorities, politicians),
health care issues in the narrow sense are fundamentally determined by
a particular professional group. |
| 2. Based on the elicitation of real needs, from which the activity plan is drawn up. Programmes are composed so that the activities proposed can be implemented in the local context, from local resources. | 2. Standardised methods are worked out to survey life quality needs.
These methods enable monitoring to be systematic and intercomparable. |
3. Pursuit of the plan is voluntary. The objectives of the
health plan will only be attained if its principles are
followed by citizens voluntarily, and not by external
pressure, to the same extent as the authorities that
largely set living conditions and circumstances. This
voluntariness gives rise to the principle, "everybody is
a partner". Nobody is being "acted upon"; the activity
is conducted by equal partners. | 3. Offers both members of the local community and decision-makers recommendations and practical (realistic) lifestyle models. The means by which the health plan is implemented is persuasion. |
| 4. The health plan must be "soid". The key to gaining acceptance - selling - openness. | 4. Every stage in the process of drawing up and implementing the health plan takes piace in public, with community involvement. Analysing the situation (identifying the problems) and drawing up the activity plan takes piace in public, and involving the public. This is the guarantee that the situation analysis will concentrate on the problems which are seen as such by the members of the community, and that the activities suggested are those that members of the community judge to be realistic. |
| 5. The health plan is not a static plan, but a process. | 5. Continuous analysis enables corrections to be where necessary. |
Selecting the strategy
One of the fundamental issues in selecting the strategy appropriate to our aims is the question oi whether the health plan for a locality is to be based on the individual or the community. These are not, of course, mutually exclusive premises. An approach based on the individual still reaches the community, but involves a different strategy from working through the community.
Good "quality of life" is not something that is achieved once and for all. It is a process, and one which requires not protection, but nurturing. What makes the process spring and burgeon is the sum of many factors. Some of these can be taken up by the individual, by eating healthily, not smoking, and not polluting the environment. Possible advantages of a planning strategy based on individuals include:
●potential usefulness for the individual even in the short term,
●direct motivation of people,
●a beneficial influence on harmful factors affecting the individual's quality of life,
●a basis in available, familiar institutions.
However, it is not certain that everybody will be willing to change by themselves. It may even be that the individual is not in a situation where he is capable of selecting the best alternative. If the prevailing attitude in a community is that smoking or dumping refuse are acceptable and natural habits, then the need to change will not even occur to the individual. The disadvantage of the individual-based approach is that its influence on the community's quality of life is restricted, it is not based on cooperation, and its effects are usually only temporary.
What the community approach sets out to do in pursuing improvement of quality of life is to involve those that provide models for the community and to offer a choice of options for individuals and various sections of local society. Its advantages are that it:
●creates models of behaviour that can be chosen from,
●influences existing models of behaviour,
●affects the entire community,
●produces permanent results,
●is based on cooperation.
This strategy brings minimal benefit to the individual in the short term, and so provides less motivation for each person. There can also be short-term communication difficulties arising from not using the familiar institutions, but relying on equal-status cooperation of people from these institutions (education, health, church, social organisations, entrepreneurs, etc.). However, this cooperation ensures that the initiatives can be sustainable and can match individual demands.
In sum: we can choose between two approaches for our planning strategy, but they cannot be rigidly distinguished. The drafters of the health plan must take local features into account in deciding which way to start out.
The health plan "schema"
In describing the "technique" of producing a health plan, we are setting out an ideal type. Preparation of communities' health plans must naturally take account of material and annual resources. The objectives of our health plan must be formulated within the bounds of the possible, in the knowledge of how serious the problems are, but we must adhere to the principles inherent of the "model" outlined here. Otherwise we are not producing a health plan, but effectively perpetuating old practices.
The health plan and its preparatory process
In the technical sense, a health plan is not a plan to implement a programme for one event, but a process extending over a long period.
The "process"
The first stage in producing the health plan is to compile a Health Profile. The health profile is an analytic survey, backed up by figures, of factors influencing the living conditions and quality of life of people living in the area. The health profile essentially tells us where things stand at the moment. It is from this that we can work out what has to be done so that the quality of life of local people can improve.
The findings of the health profile form the basis of the Activity Plan. The activity plan is a set of proposals to be offered for implementation by the actors in the health plan.
The key element in the whole process of producing the health plan, but especially in implementing the activity plan, is openness. Since there is no authority behind the health plan forcing its implementation, we have to "sell" its ideas to the people whose activity will put the programmes into effect.
The measure of accomplishment of the activity plan's recommendations (i.e. the success and effectiveness of the programmes) will be the extent to which the condition described in the health profile changes. Keeping track of changes in living conditions and quality of life, and the consequences of these changes is what is referred to in the diagram as Monitoring.
The health profile will have to be refined by analysing the changes (or lack of them) that result from these efforts, and the objectives in the activity plan modified accordingly. The effect of this feedback is thus to return the process of producing the health plan to the beginning.
The first stage: the health profile
Consider again the purpose of a health profile. It presents the current state of affairs in a way designed to stimulate into action the people who have the power to influence the situation and who bear its consequences. We will refer to these people collectively as "actors": they are all those who will be involved in implementing the health plan (the local people, various groupings of people, civil organisations, the local authority, politicians, decision-makers, authorities, etc.). This aim implies that it is not enough just to collect information on the situation itself. We also need to know about the people concerned, the actors.
The actors are affected by the socio-economic and natural environment they live in. This arises not only from the state of socio-economic and natural environment, but also how particular people (or groups) judge their own potential for influencing this environment. Learning about the actors' own ideas, their potential effectiveness, and their appraisal of the need for change, is just as necessary a part of drawing up the health profile as gathering data on the life of the local community.
With these considerations in mind, let us look at what aspects of substance that the health profile must contain so as to provide a satisfactory basis of information for the health plan's subsequent phases.
Parts or "modules" of the health profile
The first part of the health profile is the description of the facts, the "reality" of the local situation in terms of the principal characteristics (what constitutes a principal characteristic is something that depends on local circumstances). Clearly these embrace the population's demographic indicators, its sickness and mortality figures, the natural and built environment, civil organisations, infrastructure, especially health care, etc. The cross-section of reality given by this part allow the relevant problems to be ranked in some kind of order.
Components of the health profile
The second part of the health profile is the perception by different actors of this "cross-section of reality". Different sections of local society (by level of education, occupation, ability to press their interests, etc.) may have different perceptions or interpretations of the facts characterising the locality.
In consequence, the order of priority they place the problems in can vary just as much. A specific example of this: health service problems strongly affect sections of society with a high level of sickness, such as the elderly. For the young and healthy age groups the same problems -because they do not consume these services to the same extent - "do not exist". So we have a problem which for part of the population is important and needs to be addressed, and is not even perceived by the rest.
The opinions of different groups of actors on each fact gives rise to "subjective rating" of problems. Without knowing these subjective ratings, the willingness of the various groups to cooperate groups will be uncertain. It must be stressed that the term "actors" does not just mean the local residents, but everybody who has a role in drawing up and implementing the health plan: politicians, experts, teachers, health workers, local authority workers, church representatives, and other people prominent in local life, such as business people. Their knowledge, beliefs and attitudes are all crucial to the quality of life of the population of a community. The decisions made on the basis of these knowledge, beliefs and attitudes can determine the living condition of the residents for long periods.
The third part of the health profile describes the actors themselves. Those actors who "set the facts of the community" must be identified in the health profile. Who can be relied on with certainty, and who cannot, and who has the power of persuasion. What we have to do to involve them in shared activity, how we can stimulate their interest, etc. It is not enough just to think of local political and economic actors in this regard. Certain habits characteristic of local people's lifestyles can also have serious consequences on the "facts of the community".
The fourth part is closely related to the first. It is not enough to "survey" the actors, we also have to know whether we can rely on their participation, and whether we can stimulate them into action. In order to get beyond mere declarations and elicit actual action (which in many cases will involve making sacrifices for the sake of their own health and that of other members of the community), the people who indicate some motivation towards change must be presented with models of how to proceed. Drawing up models and testing their feasibility is also a health plan task.
"The technology"
There are a range of means by which the health profile can be compiled:
We can employ a range of different data-gathering and analysis techniques. Much information needed for compiling the health profile is available in forms of varying usefulness from local government and authorities. In this case the most appropriate technique is secondary analysis.
The documents which have accumulated in the community can be rich sources of information. Analysis of these can yield facts unobtainable even from authorities with mountains of paper. (Local authority resolutions, by-laws, minutes, etc.)
The third group of methods employed is direct data gathering (by questionnaires and interviews, or just by ordinary conversations). This enables us to obtain information on the actors' ideas, how much weight they ascribe to the existing facts, and how active they are prepared to be.
How is a health profile produced?
First we have to decide who is going to produce the health profile. It is not a one-person task. We have to identify the people who can produce it and find out if they are willing to do so, and then assign them different parts of the work with appropriate deadlines.
We have to decide which of the sources available to us are worth using, and assess what kind of facts they will yield for the health profile.
And at the very outset of the venture, we have to identify the target groups whose "activation" we want to attain by presenting them with facts gathered into the health profile. It must constantly be borne in mind regarding the health profile, just like every other element of health plan, that the people who will read it and use it are the members of the community themselves! It must present the current situation in a way that can be understood by the ordinary population. And it must encourage the residents of the town or village to change the current situation. A health profile which becomes known to only a few people beyond its authors will have no effect.
What headings should a health profile contain?
The form of the health profile differs among different communities depending on the kind of information available and the skills of the staff who produce it. However, there are certain headings, those concerning the basic characterisation of the area, which should be included in every health profile. Although the precise form may be varied, these essential components are:
●The community's demographic characteristics (population, age, sex, composition by age group, etc.). The data looked at should extend some way into the past so as to show up trends and changes. (For example, it may be important to know how the population and age composition has changed over the years.)
●Figures and balance of births, deaths and movements in and out (migration)
●A look at the community's situation viewed through figures for public services (such as: the number of residential houses, annual construction figures, the number and proportion of houses with piped water and gas, the number of houses connected to public drainage, waste collection arrangements, etc.)
●a survey of the civil and non-profit sectors (what kind of civil organisations, enterprise groups and companies can we look forward to involving in pursuing health plan objectives, and how can the role of the civil sector be reinforced during the process so as to have a catalyzing effect in building the community.)
Further suggested components (not given in any order of importance)
●The health of the local population
●Comprising sickness, mortality, doctor attendance rates, etc., and highlighting the outstanding features.
●Local lifestyles
●The prevalence of harmful habits (smoking, alcohol and drug consumption) and aspects of habits beneficial to health (leisure-time sport, eating habits, etc.)
●Mental health
●May look at problems suffered by specific groups, such as the elderly (loneliness, depression arising from helplessness, reduction of ability to act autonomously), underprivileged children (social difficulties, inborn nervous system disorders, psychological disorders), socially disadvantaged families (sickness, single-parent families), suicide, alcohol abuse, etc.
●Living circumstances
●Relevant information may include housing figures (e.g. housing density, number of rooms, level of amenity, etc.) and local amenities (number and type of shops, cinemas, etc.)
●Social and economic conditions
●Covering aspects of education, employment, income, crime, and cultural services, and possibly extending to the availability of work and commuting habits, etc.
●The natural and built environment
●A characterisation of the natural environment using indicators such as air and water quality, noise, sources of pollution, etc. For the built environment, a possible technique is to identify differences between parts of the town or village, and describe "run-down" areas, etc.
●Social inequality
● Figures may be given here for the numbers receiving social benefits, medical services and unemployment benefit, or figures relating to ethnic minorities.
●Infrastructure
●Possible subjects may be the area's accessibility (surfaced roads, railway connections, regular bus services), telephone lines, local communications (such as regularly-appearing publications, local cable television), etc.
●Health services
●For example, a description of the service providers and their capacity (numbers of doctors and health visitors, surgeries, access to specialist services, etc.)
●An analysis of local opinions regarding the problems of the area could also be valuable to the health profile
●For example, an account people's experiences regarding community forums and access to authorities, or insights from a survey into problems particular to the community, etc.
●The local assistance system
●This may include a description of the professional aid providers concerned with problems in the area (local doctor, health visitor, nursery nurse, teacher, etc.), civil helpers (in sport, culture, religion, etc.) other people who indicate willingness to help, foundations (approx. charities), business people and external resources available to the community (support professional groups, institutions, etc.)
Sources
Much of the data needed for producing the health profile can be obtained from existing sources. Such are:
●The national Central Statistical Offices' yearbooks and other publications. In many countries these publications give major figures broken down by administrative units (towns and villages). These figures can be used for detecting trends which have developed over time. Efforts to examine these trends, and to make comparisons on national and regional levels can be very worthwhile. They can tell us where our community stands and where it is going in relation to others.
●Local authorities also hold useful data. Using this requires us to consider the context in which it
was compiled, and not look at it through "official eyes".
●Data can also be obtained from schools (school diaries, for example), local doctors, and the local police, etc.
●Excellent information can be gained from studying minutes of village/ town assemblies and community forums, and letters of complaint from members of the community, and the value of conversations with local people should not be underrated.
Second stage: the activity plan
The activity plan is based on the facts adduced in the health profile. The tasks it sets out are those that public consensus has identified as necessary to effect beneficial change in the health of the local people. Its recommendations are directed at particular "social groups" that will be involved in and affected programmes to protect and improve health.
The activity plan aims to provide feasible, relevant lifestyle models and recommendations which
●have clearly-defined aims and can be managed within the authority of the local authority or the local community
●lead to perceptible effects and measurable results in the short and medium terms
●have realistic chances of being implemented through the influence and financial resources of local decision-makers
● provide means for trial implementations of the models recommended.
This phase calls for the application of numerous different "techniques". The "repertoire" extends from identifying current models and existing problems regarded as such by common consensus to the "operation" of various small social groups (parents, housewives, garden-lovers, people who brighten up the environment, etc.).
It is most important that there be constant opportunities for trying the models out and that people who want to get involved in solving the community's problems get the chance to do so. The activity plan must also engender commitment among all the different actors, and real opportunities for involvement.
How is an activity plan produced?
The finished health profile must first be conveyed to members of the community. The simplest way of doing this, and one which provides opportunity for immediate feedback, is to arrange community meetings (village/ town assembly, residents' forum, school staff meetings, etc.). Here we can put over the findings of the health profile, discuss the problems to be addressed, their order of priority, and how they are to be tackled.
Discussing the health profile with members of the public is efficient if:
●we have already communicated the main facts of the health profile by taking advantage of available channels (such as local cable television, or in the simplest case by posters in the mayor's office, etc.) prior to its detailed presentation.
●we are well prepared for discussion (prioritisation) of the problems and of proposals for addressing them (and we have our own preliminary suggestions that we can put forward if necessary). On the other hand it is important not to "dictate" to the local people, because this may dull their enthusiasm for community activity.
Discussion of the facts and findings of the health profile requires that the team managing the preparation and implementation of the health plan must already have the sketch of a health plan (i.e. a plan for addressing the problems). The health plan itself must, however, evolve as the result of consensus and a joint decision-making process.
Essential considerations for the health plan
Its proposals must address the problems which affect the most members of the community, which the most people want solutions to and which the largest number of local residents are prepared to participate in solving.
It is essential that the first joint "operation" be a success. We therefore recommend the adoption of projects with realistic chances of realisation, that will prove to members of the community the worth and reward of joint efforts. Only after this should we set to tackling more serious problems demanding greater effort.
How should the health plan (activity plan) be drawn up?
After the facts of the health profile have been analysed and the opinions of community members learned, we can put together the "outline health plan". This outline will have to be modified in the course of its discussion among the community. The activity plan should meet with the agreement of as many people as possible.
And another technical aspect...
Selection of key problems
One of the most important results of producing the health profile is that it gives a clear picture of the problems which have adverse influences on the community members' quality of life, and thus their health.
As mentioned several times already, the community has to produce a strategy for improving quality of life, i.e. the health plan. One of the most difficult aspects of this is to decide which of the numerous problems it should concentrated on.
What follows is a method for determining strategy, i.e. for selecting the most important problems that have realistic chances of solution.
The health plan will bring to light a great many facts with adverse implications for the quality of life and health of community members. All of these need to be addressed, but some of them will have to be left out of the health plan. We have to "select" those problems we will tackle immediately, those we will leave to a later stage, and those for which the community's resources are insufficient.
As a first step, we should select, say, the ten most weighty problems as determined by the health profile. This is done by putting all the problems in order of importance (by scoring). Each problem's importance is determined by estimating its effect on quality of life and health.
The second step is to rank the ten most important problems by the extent to which the community and its members are competent to tackle them. Competence in this context means opportunity as provided by law, and the availability of professionals with appropriate expertise.
At the top should be the problem for which the community has the greatest "competence" to solve,
and at the bottom that for which it has the least.
This enables the selected problems to be assembled in order.
In the third step we rank the ten problems selected in the first step by a different criterion: the extent to which resources needed to tackle them (like money) are available to the community. The problem requiring the least resources goes in first place, and that requiring the most in last place.
The fourth step is to order the selected problems by both criteria. This procedure results in the matrix below:
Resource requirement
As the example shows, problems are put into different cells of the depending on how much resources and "competence" they demand. The optimal health plan as regards chances of realisation is one which sets solutions to problems in cell I as its objectives.
For problems in cell III, the community must seek external resources.
If problems in cell II are to be tackled, achieving a sufficient level of will take up the most effort. (An example may be lobbying to change statutory provisions, involving external expertise in solving the problem, etc.).
The community has the least chance of solving problems that fall into cell IV. There is neither the expertise nor the level of resources available for dealing with them.
In summary, then, we recommend drawing up a strategy which concentrates on solving the problems that the community can manage best. A demonstrable result, even a modest one, is the best foundation for spreading confidence in the health plan's effectiveness.
The third stage: health plan communication
Openness is crucial in putting the health plan into effect. The aim of the communication phase is to spread awareness of the health plan in all its aspects, and through continuous exposure, to open up individual motivations to change and produce new models of behaviour to choose from. Communication is not a one-way process, and is not just aimed at the public, but also at politicians, decision-makers and professionals. It is in the communication phase that implementation meets the greatest difficulties. Every opportunity must be taken to reach those involved (local publications, leaflets, village/town assemblies, parents' meetings, etc.). Of course the most effective communication of all is the successful outcome of the health plan.
People running the programme
The basis for drawing up the health programme for a village is the opinion of the village community members themselves. It would be impossible for the programme to be run successfully without community members' active participation.
As with every programme, it has to be directed and organised so that the multitude of ideas and actions that are generated do not result in duplication of effort and dissipation of resources, but are channelled towards an effective and successful outcome.
Who "organises" these programmes? There is no single correct answer to this question. The villages themselves have to decide which organisation, institution or perhaps autonomously-organised group is best placed, under the prevailing local circumstances, to coordinate the community's efforts to improve its members' health. In many cases the organisation is the local authority, and in other places programmes are centred around a local institution such as a school or community centre. There are some programmes, however, run by civil organisations, a form of operation that is still in the process of evolution.
One of the most important aspects of Soros Foundation's mission - especially in the Central-Eastern Europe region - is to assist via its own means and programmes the creation and reinforcement of civil organisations (In the (Hungarian-language) publication on the Community Health Plan project, there is a chapter dedicated to civil organisations and the legal and organisational aspects of setting them up. We recommend that the creation of civil organisations should also be included when the publication is produced in another language, and in the preparatory training material for applicants.). Strengthening the civil sphere is one of the most important steps towards the open society.
However, this is not the only reason why it is important for civil organisations to take on "leadership" of a program based on the pooling of community resources. Democratically-run civil organisations can be the proof that the programmes are not tied to election cycles, are not at the mercy of politics, and are not implemented according to the logic of political practices.
One of the main results of the Soros Foundation's Health Plan programme is that it has been the inspiration for the creation of civil organisations in many villages. Sometimes this was just the final step in a process, but in others it was recognised that running the programme would have been much harder without it.
Health plan, quality-of-life improvement — the programme could be characterised in several ways. But ultimately, what is the programme about if not democracy itself?
The Soros Community Health Plan programme
It is obvious that producing a health plan demands an attitude different from what people are used to in the areas where it will run. Ideally:
● the activity plan is based on a broad-based analysis, which is carried out by local professionals but known to members of the community at large,
● the elements of the activity plan are decided with the involvement of community members by means of consensus developed among them,
●implementation relies on the active participation of community members,
●the outcome of programmes is continuously monitored,
●the programme is not produced for a single occasion, but sets off a process.
In providing the initiative for community health plans and supporting them as they are put into effect, the support provided by the Soros Foundation must not be confined to programme implementation; it must also help the communities producing the plans to change their attitudes.
The Hungarian Soros Foundation drew up an innovative grant application scheme for its Community Health Plan programmes, with the aim of promoting changes in attitude and encouraging communities to realise that they can meet the conditions by drawing on their own resources, which means above all the strength of the community itself, and that they have the ability to create their own health plan and put it into effect.
New approaches and methods introduced by the Soros Foundation
To accompany the new-type community health plan grant schemes, the Hungarian Soros Foundation drew up "grant application tools" aimed at helping communities applying for grants under the community health plan programme to make their applications successful. These "application tools" employed five completely novel elements.
The need for new methods for supporting applicants arose not just from the innovative nature of the programme, the lack of precedents to draw on, but also the need for applicants to satisfy a major pre-condition: the production of a health profile for their village (The Soros Foundation started up this programme for villages in 1997, and it has been extended to towns in 1999.).
The services provided to assist applicants were:
● A "personal invitation" to villages to take part in the scheme
● -The letter sent to communities was mainly aimed at eliminating inequalities in access to information.
In the letter announcing the grant scheme we also explained to communities what assistance we could provide for preparing the application. Under both of the community health plan grant schemes to date, we sent letters to all village mayors in Hungary (this was more than 2900 letters each time).
● Training for representatives of interested villages
● -Prior to the application date, we held a training session for representatives of communities who were interested in producing community health plans. This one-day event was organised at several venues across the country, so as to make participation for enquirers easier.
● -Representatives of some 19 % of villages in Hungary took part in the training sessions, and covered the aims of the health plan, how to produce it, and what it should contain. We discussed questions that participants brought up concerning the health plan and writing the application.
● Application guidelines
● -We compiled a detailed set of guidelines for communities applying for the Community Health Plan programme. The guidelines went beyond the concept of the health plan to give detailed information on how it should be produced. It included a section on application-writing "strategems" and a clear and detailed example of how a local NGO has to be set up under Hungarian law.
● Telephone consultation
●-In the weeks prior to the application date, applicants were given the opportunity of consulting expert advisers by telephone, to help them solve any problems that arose with their communities' applications.
●Written assessment of applications, and informing applicants of the assessment
●-The experts produced a written opinion on all applications submitted for the community health plan. These included rating the standard of each element of the application and analysing the proposed programmes. Each applicant received the written assessment which concerned it, so that it could correct any errors or deficiencies when producing a subsequent application.
Newsletter
We launched a newsletter for communities who participated in the community health plan programme.
The Newsletter serves several purposes. We would like to highlight two of these here:
● by publishing accounts the winning applications and communities we aim to assist later applicants to a better understanding of the programme's essence, so that their own effective health plans can be produced more effectively.
● the Newsletter provides a forum for villages developing health plans enabling them to draw support for their efforts to build a community, to strengthen their identity, and thereby to enhance their autonomy.
Three issues of the Newsletter have appeared so far.
Experiences so far
The Hungarian Soros Foundation has announced the second round of the community health plan programme. Under the two schemes, 273 villages have produced health plans or health plan applications.
The following is a brief summary of observations regarding these applications.
● Producing the Health Profile
● -Producing the health profile was a condition of submitting the application. In contrast with our expectations, and with applicants' reservations, the analysis of the community's present condition produced the fewest problems for villages. (There were of course some of an extremely high standard, and others that were somewhat less thorough.)
● -An interesting finding is that the health profiles were good, authentic, and produced by professionals who live in the community (teachers, clergy, local authority workers, etc.).
● Activity Plan
● -Drawing up the health plan's activity plan proved somewhat harder for applicants, involving as it did a change of attitude.
● -The most problems were caused by many applicants who put themselves forward in the name of the community not having sufficient confidence in the people of the community, and so their approach was patronising or paternalistic. (For example the mayor and a few professionals "knew" what the people of the community needed, and wanted to "give" it to them using support won from the Soros Foundation.)
● -The thinking of these applicants was not directed towards the launching of a process, the strengthening of a community, the evolution of active community involvement, but towards single projects, and "educating the public".
● -Communities are still unpractised in pursuing their own affairs. This was proved to us by the frequent observation of difficulties in planning the scheduling and efficient use of resources for the programmes.
● -The overall outcome of our experience is that the community health plan programme has helped a new process to get under way in Hungary. Over a period of years, this process should lead to smaller communities gaining self-confidence and greater autonomy, and becoming capable of effectively managing their own problems.
Produced for the Soros Foundation
Publication coordinated by Dr Zsuzsanna Füzesi,
Director, the Fact Foundation
Design by molnARTamás Drawings by Istvan Tóth Printed by Reproflex Kft., Pécs