Primary health care was ratified as the health policy of WHO member states in 1978. Participation in health care was a key principle in the Alma-Ata Declaration. In developing countries, antenatal, delivery, and postnatal experiences for women usually take place in communities rather than health facilities. Strategies to improve maternal and child health should therefore involve the community as a complement to any facility-based component. The fourth article of the Declaration stated that, “people have the right and duty to participate individually and collectively in the planning and implementation of their health care”, and the seventh article stated that primary health care “requires and promotes maximum community and individual self-reliance and participation in the planning, organization, operation and control of primary health care”. But is community participation an essential prerequisite for better health outcomes or simply a useful but non-essential companion to the delivery of treatments and preventive health education? Might it be essential only as a transitional strategy: crucial for the poorest and most deprived populations but largely irrelevant once health care systems are established? Or is the failure to incorporate community participation into large-scale primary health care programmes a major reason for why we are failing to achieve Millennium Development Goals (MDGs) 4 and 5 for reduction of maternal and child mortality? This article discusses these questions and reviews the literature on the subject. It concludes that community mobilisation can bring about cost-effective and substantial improvements in maternal and child health, and have non-health benefits too, but that it is not a feature of most large-scale primary health care programmes because of several fundamental controversies (about its effects and how it should be done) on which further research is needed.
The Lancet (2008) 372 (9642) pp. 962-971 [doi:10.1016/S0140-6736(08)61406-3].