Community-Based Health Care: Health and Rehabilitation from the Bottom Up

The term ‘community-based’, when used for health programs, has come to mean something different today than it did several years ago. The concept of ‘community based health care’ evolved principally in the Philippines. It has its roots in the Spanish expression ‘comunidad de base’ – essentially a community of working people who find strength in unity and who organize themselves in a struggle for their rights.

Thus, the original concept of community based has a political and egalitarian foundation. It is no surprise, then, given the institutional injustice in the Philippines, that for a time the term became officially taboo and that many programs known to be ‘community-based’ suffered repression.

As so often happens, though, some governments and international agencies co-opted and misused the term. They began to use it, not for programs that grew out of local people’s self-directed action inresponse to urgently felt needs, but for programs that were planned and directed centrally or internationally, and then implanted into poor communities for ‘community participation’ (another co-opted and misleading term).

Because of the present misuse of the term ‘community based,’ some community groups that have organized themselves into programs of self-directed action now refer to them selves not as ‘community-based,’ but as ‘community directed’ or ‘community-controlled.’

Both Projects Piaxtla PROJIMO are organized and run by local villagers. Goth programs believe that a healthier more just society will only come about by the united efforts of ‘los de abajo’ -those on the bottom.

The Project PROJIMO Team

Project PROJIMO, run and staffed by a group of 20 disabled villagers in collaboration with the local townspeople, is also committed to a fairer society. The team has come to realize that the low acceptance and lack of opportunities for the disabled in the larger community is but one part of a social structure that mistreats or misuses all who are weaker or different from those in control. They feel that as disabled persons, they must join in solidarity with all who are mistreated, misjudged, or exploited. The struggle for the rights of the disabled is part of the larger struggle for equality and social justice for all the world’s people.

Project PROJIMO, run and staffed by a group of 20 disabled villagers in collaboration with the local townspeople, is also committed to a fairer society.

The quest for a fair social structure needs to start at home. The PROJIMO team has been experimenting, within its own group, with approaches to equitable self-government. But for a group to learn to work together within a framework of trust, equality and shared responsibility is not as easy as it sounds. Some kind of leadership and coordination is needed. In an environment, though, where people are used to a boss/laborer work relationship with its inevitable conflicts of interest, misunderstandings often develop when a group tries to support leaders whose role is to represent the group fairly. After many trials and errors, the PROJIMO team is now trying out a system whereby they elect two ‘coordinators’ (rather than directors), one for meetings and one for activities. Each month they choose new coordinators so that everyone will have the chance (and will recognize the difficulties) of equitable leadership.

Nevertheless, among the PROJIMO team, as within any group, there are certain individuals who have an exceptional ability both for leadership and for human relations. These persons seem to have a skill of bringing people together, of working out difficulties, and of helping the others feel good about themselves and their place in the group. In PROJIMO, Mari is such a person.

Newer and Bigger Responsibilities for the PROJIMO Team

Mari is one of seven spinal-cord injured young persons currently at PROJIMO on a long-term basis. Unfortunately, all arrived with pressure sores, some of them longstanding and life-threatening. Most had developed the sores in the hospital when undergoing treatment following their accidents. By the time they came to PROJIMO, some, like Mari, had already developed bone infections in the sites of their sores.

All this is in addition to the urinary and bowel problems that are common for those with spinal cord injuries. This means that the PROJIMO team has to provide a wide range of fairly continuous services such as nursing and laundry as well as attending to rehabilitation needs. They also produce wheelchairs, therapeutic aids and orthopedic equipment for the hundreds of disabled children who arrive each year. This increased work load has forced the PROJIMO team to seek more effective approaches to teamwork and group monitoring of responsibilities.

In the last year the PROJIMO team has been doing much more to share its methodology and technology with other persons, programs, and communities:

At the local level, PROJIMO has been involved in working with and helping organize families of disabled children in different villages and even urban ommunities. So far, two small ‘satellite programs’ have started in larger towns near the coast. PROJIMO has taken school children from Ajoya (where PROJIMO is located) to these towns where they worked with children and families to set up simple ‘playgrounds for all children’ where disabled and non-disabled children can play together.

Further afield, PROJIMO has reached persons from health and rehabilitation programs in various parts of Mexico, Latin America and beyond to exchange ideas and learn from the PROJIMO approach.

Through a collaborative effort with UNICEF, two 11-day workshops were held at PROJIMO in February and March. Participants came from health and rehabilitation programs in Mexico, Guatemala, Honduras, Belize, Costa Rica, Nicaragua and Panama, hoping to introduce aspects of the PROJIMO approach, philosophy and appropriate technology into health and rehabilitation programs in their own countries. Taking part in both these workshops was Don Caston, a British engineer who for 15 years has helped design low-cost rehabilitation and therapy aids in African and Asian villages.

It is interesting to note that the visitors who seemed to enjoy and learn most from the PROJIMO experience were those working directly with families and children in the communities, or with refugees. For the most part, those holding important positions in urban rehabilitation centers felt out of place in the village and awkward in trying to relate to disabled village workers as equals. The workshop reinforced the PROJIMO team’s commitment to work ‘from the bottom up.’

Apprenticeship opportunity. One of the best ways to ‘seed’ the PROJ IM0 approach community-controlled rehabilitation' is for the PROJIMO team to accept apprentices (preferably disabled and with strong human commitment) to live and learn with the PROJIMO team. The team feels that the process is as important as the technology.

The first outside ‘apprentice’ was Margarito, a young man who is disabled in both legs from polio. He was trained as a village health worker in Alamos, Sonora in a community health program sponsored by Save the Children, U.S.A. Margarito accompanied a child from his home area to PROJIMO who came because he needed braces. Margarito learned to make the braces himself and he returned to his own village to continue his health care work. Like Margarito, a U.S. nun working in Brazil also apprenticed for a few months a year ago.

The newest apprentice with the PROJIMO team is Mario, a young man with paralyzed legs and a mild speech impediment. He was sent by a community health program in Hermosillo, Sonora, sponsored by Project Concern in San Diego. Mario plans to stay three months and then help the Sonoran community program launch rehabilitation activities utilizing PROJIMO ideas best adapted to their own area. (PROJIMO does not feel that its approach should be ‘replicated’ as it is. This is partly because it still has many weaknesses to overcome, and partly because replication denies the participants in each community the adventure of designing their own program according to the unique needs and possibilities of people in their area.)

Through this plan, we invite you to help purchase a wheelchair, leg braces, or basic therapy for a disabled child that can open the way toward a fuller, more independent future for that child. What is more, the wheelchairs and braces are made, and therapy services are provided, at exceptionally low cost by a village team of disabled workers. The team is able to provide a wide range of good-quality rehabilitation equipment and services at costs far lower than those available in the cities:

Unfortunately, although the PROJIMO team provides these services at such low cost, a poor family with average earnings of $5.00 a day (when work is available), sees the $140 needed for a wheelchair as a huge expense. The typical family has no savings and is often in debt. Each family is asked to pay PROJIMO what they can, but most can only pay a fraction of the costs of rehabilitation services and equipment, even at the low PROJIMO rates. For this reason, we are asking you to join in an unusual partnership: become a PROJIMO sponsor.

PROJIMO Sponsors are persons who give tax-deductible donations on a regular basis to the “disabled children’s service supplement fund.” These monies, given as donations to The Hesperian Foundation, are not outright grants to the PROJIMO team. They are only used when a poor family cannot pay the entire fee that the PROJIMO team must charge for services or equipment. After the team provides its service, the family pays what it can, and the rest is paid by a “silent partner” – the PROJIMO Sponsor.

Because most of these families cannot afford to pay even PROJIMO’s modest costs, the ever-increasing popularity of the program could ruin it financially, since the team has a commitment to helping everyone in need, regardless of ability to pay. With the “service supplement fund” provided by PROJIMO Sponsors, the team’s ability to serve is allowed to grow along with demand.

To become a PROJIMO sponsor, please write to us and let us know how much you can give regularly to the “service supplement fund.” We are asking for a minimum donation of $120 per year, which can be given in monthly installments of $10, or at any interval you like – please let us know. Of course, one-time donations are welcome, but please understand that because PROJIMO is a continuing program, what we need most is continuing support from persons like you who can make donations on a regular basis. Our three-year goal is to enlist enough PROJIMO Sponsors to create an annual income of $36,000 to the disabled children’s service supplement fund. PLEASE JOIN US!

Requests for Donations to Start a Revolving Fund for Independent Income Generation

Many of the young disabled persons who spend time at PROJIMO go home after their rehabilitation with valuable skills they have learned at the Project such as welding, carpentry, leatherwork (sandal making and shoe repair), toy making, sewing and dress making, furniture making and weaving, bee keeping, and wheelchair making. If these young persons could purchase basic equipment to set up their own shops, they would have a chance not only to become more economically independent, but to provide much needed services in their communities. Also, they would give an example to their neighbors that the disabled can learn important skills, become self-reliant and play a valuable role in their communities. They need money, however, to do this.

Polo, for example, who is disabled by polio and uses a wheel chair, is one of the key crafts persons now making wheelchairs at PROJIMO. Because Polo has mastered welding skills, almost every day villagers come to Project PROJIMO and ask him to repair broken equipment such as bicycles, tools, plows, machinery and truck chassis. In this way, Polo has brought about closer relations between PROJIMO and the local community in Ajoya, and a deeper appreciation for the abilities of the disabled. (The able-bodied now come to the disabled for work no one else in town can do.)

Polo enjoys working with PROJIMO, but sometimes says he would like to become independent and set up his own welding shop – perhaps even make wheel-chairs independently.

It would be nice if PROJIMO were able to provide a no- or low-interest loan to Polo and other disabled young persons to set up shops in their own communities. But the Project does not have the funds to do this. We would like to set up tile REVOLVING FUND FOR INDEPENDENT INCOME GENERATION in order to meet this purpose.

As loans are paid back, the money could be used to get others started. Thus, the revolving fund would repeatedly help launch young disabled persons toward economic self-sufficiency. Similar programs in Jamaica and elsewhere have shown that disabled persons who received loans to start small businesses have a better track record in paying them back than the nondisabled.

In this proposal, PROJIMO would like to start small. We are looking for a start-up revolving fund of about $10,000.00. For anyone interested in major sponsorship, we would be glad to discuss further details.