Dr. Peter Muennig in Burma.
Many directors of non-governmental organizations feel that they will best serve a target population by maximizing their fiscal resources. At first, we thought this to be true, too. But we learned that, in some cases, this approach not only comes at a high cost, it may ultimately be less effective than a “ground-up” approach—one in which members of the community actively contribute to the project, even if they appear to take long and winding roads.
Fortunately, while we had to learn this hard lesson, we did not have to learn it the hard way. The project directors we worked with began as outsiders, too, but they had worked long enough with the community we served that they were completely trusted. They taught us that paying members of the community to do the work would likely lead to dependence and little participation in the services that we would ultimately create. Every time we wanted to buy bricks, the managers implored us to let the members of the community find a creative solution to putting in a latrine. And, lo and behold, they built the latrine with only the cost of expensive porcelain borne by our organization. Deciding where the latrines would be located in their household cluster, what they would look like, and who would maintain them were integral to the process. The latrines also made use of construction skills they had already learned as day laborers.
Thus, from its inception, our organization, the Burmese Refugee Project, was built around the idea that social capital, not fiscal capital, was what ultimately helped our project to succeed. One goal of our organization is to engage members of the community so that they can take ownership of their health. In a severely under-resourced community, this usually involves the basics: building latrines to prevent soil and water contamination, providing vaccines to reduce the transmission of vaccine-preventable illness, assessing and intervening on nutrition, providing health education, and providing basic literacy and numeracy skills. Because most of these services were labor- rather than resource-intensive, we were able to provide these services to a community of 180 people at a cost of $3,000 per year.
Of course, the central consideration one has in starting a project surrounds the local conditions and the people the project serves. The Shan are one of the largest ethnic groups in Burma (also called Myanmar by the ruling junta). They have been engaged in a decades-long armed conflict with Burma’s military dictatorship, which has ruled the country since 1962. As a result of this conflict, over 1 million Shan Burmese civilians have been internally displaced from their homes and villages, with as many as half a million migrating into neighboring Thailand. They confront a wide range of psychosocial problems and work long hours, but they are also very concerned about their health and the health of their children. Because of their forced migration and precarious positions in Thailand, the refugees were a lot more comfortable with informal, negotiated initiatives than institutionalized, “flashy” programs that they feared might attract unwanted attention.
But all this organizing takes a lot of work. The project managers had to spend a lot of time with the community members, going hut-to-hut to communicate the importance of latrines, vaccinations, clean water, and, most importantly, of the act of organizing the community itself. This relationship-building proved essential when the BRP began to work with community members on more sensitive issues, such as substance abuse, domestic violence, chronic stress and trauma, reproductive health, and gambling.
International development is littered with failed, expensive capital projects that could have been more successful with community buy-in. Certainly, organization will not work in every village or in every cultural context. But it is critical; if we had been unsuccessful at engaging the community, we doubt that we would have been successful at implementing a public health program—at any cost.
For more information, please click Burmese Refugee Project.
Dr. Muennig is an Assistant Professor of Health Policy & Management at Columbia University's Mailman School of Public Health