Summer 2002 Research Report Adebiyi Adesina "Sustainable Rural Health Development through Civil Society in Nicaragua"

My project in Nicaragua involved observing and evaluating a community program that uses community participation and empowerment as a means of rural health development. I worked with Accion Medica Cristiana, a local non-governmental organization, and I lived in the town of Laguna de Perlas which is located in Autonomous South Atlantic Region of the country. The municipality of Laguna de Perlas, like many rural areas of Nicaragua’s Atlantic coast, a diverse group of people; Creoles (Criollos), Mesitizos, Garifunas, Rama Indians and Miskito Indians. These multiethnic, multicultural communities make for the most diverse of AMC’s projects.

The prevailing political and socio-economic circumstances in the country and region reflect a state that is still very much in the development process. Political factors such as the central government’s slow process of relinquishing autonomy to the region, the development of a regional government, and the struggle to ensure indigenous and territorial rights as well as human rights continue to stifle political and socio-economic development of the area. These factors as well as many others, contribute to such problems as high unemployment rate and more than half of the population leaving below the poverty line. Even though there are a few government agencies present in these rural areas , in the form of the Alcaldia (Municipal government) and the Nicaraguan Ministry of Health (MINSA), the services provided are still below average because primarily because of greatly limited resources. As a result of this, Non-Governmental Organizations continue to be the only means of providing social services to most of the population.

The Acción Médica Cristiana Laguna De Perlas Project first came into the basin area in 1988, shortly after Hurricane Joan, during the Sandinista – Contra war. In 1992 AMC moved from its role in assistance and prevention to commence its project on health integration. It was not until 1998 that the organization initiated ‘community health development’, with the objective of improving the development of the community by including the community in the decision making process of community development. This later laid the foundation of the organizations 2001-2003 tri-annual goal of ‘community empowerment through health development’. The objectives of this plan focused on three specific issues that contribute to the empowerment of communities: Developing a Community Health Model, Community Development and Empowerment, and Gender and Equity.
The project works with five communities in the area; Laguna De Perlas, Haulover, Awas, Orinoco and Tasbapounie, but it also provides support to some of the other 13 communities in the municipality. The main focus of the project has been to build a sustainable capacity in community agents, using prevailing health issues such as STDS, gender and health, and drug abuse as a focal points. These community agents exist within community organizations; Health Leaders, Midwives, Health Brigade, Women’s groups, Women Health Promoters and a Health Committee. These community agents act as channels for building the capacity of the community, which should eventually lead to empowerment of the communities.

Community Capacity in this case, refers to the community’s ability to actively confront the problems of health, gender and development. However, community empowerment refers to a more elaborate description, which involves individuals and organizations collectively using their skills and resources to meet their respective needs. An empowered community is one in which there are opportunities for citizen participation in decision-making and interaction between individuals and organizations. Through this participation and interaction, individuals and organizations support each other, address conflicts within the community, and in so doing the community has the ability to influence decisions and changes in the larger social system.

My project in the organization was to develop and implement a means of evaluating two aspects of the program’s goals, to assess the planning and implementation process from the perspective of the local team, and to assess the level of the capacity of the community organizations and the cohesiveness of these organizations. Because of the nature of the project’s goal as a community empowerment program, I decided to employ a more flexible and participatory approach to evaluating the program. I had the option of doing one-on-one interviews, surveys, group observations and focus group interviews. I decided to use the latter because of the limited time and the need to involve and inform the participants in the evaluation process. Each focus group session involved a guided discussion, were participants talked freely and spontaneously about themes considered important to evaluating the project’s planning and implementation processes.

The goal of the first assessment was to assure a participatory evaluation process that would empower the local team, build their qualitative assessment skills, provide a means for organizational self-reflection, all of which would inform the next round of annual planning at the end of the year. This evaluation revealed that the local team felt they needed more technical training and planning and evaluation so as to be able to participate more actively in the planning process. The evaluation also revealed that the previous year’s plan did not adequately address the communities’ perspectives, specifically with regards to STDs and drug abuse; as a result the local team were not well organized to properly implement the annual plan. Most importantly the evaluation revealed that the communities had begun to develop a dependence on AMC to initiate community organizing programs. The concluding recommendation of this evaluation suggested, amongst many things, that the local team be given more technical training to have more local control and direction of the project, and a re-assessment of the sustainability of the project so as to properly address the dependency of the communities.

The next stage of the evaluation process, which will begin upon my return to Pearl Lagoon in September, will be to assess the level of capacity of the community organizations and cohesiveness of these organizations; using a combination of the participatory evaluation methods outlined above.

My field experience in Nicaragua has not only honed my analytical skills in program assessment, it has also helped me understand the complexities and level of commitment that is necessary to effectively and sustainably plan and implement a community empowerment project. It is my hope that the rest of the evaluation process will help me understand better civil society’s participation in the establishment of sustainable development for rural areas of developing countries.