Deciding on priorities, objectives, and action
For a programme to succeed, we must know clearly what we want to
do and how we are going to do it.
In the first sections of this chapter, we discussed how to find
out the needs of the individuals, groups, and communities we are trying to help.
People usually have many needs. It is not possible to do everything at once,
therefore we must decide which problems we will try to solve first. This is
known as setting priorities.
After people have decided upon their priority needs, they can
think about what must be done to meet those needs. They must spell out exactly
what they want-in other words, their objectives.
Then with an understanding of the problem and an eye on the
objectives, they can consider how best to deal with the problem, that is, what
action to take. This is called developing a strategy.
People must determine what their priorities and objectives are,
and what strategies are acceptable to them. To do this, they need professional
help, but the members of the community must make the final choices.
Setting priorities with individuals
It is not always easy to know what problem to face first. People
have many pressing problems like those of the family described opposite.
Mrs Antia has five children. The oldest is eight
years old, and the youngest nine months. Mrs Antia is pregnant again. The family
shares one room, made of boards and metal roofing-sheets, stuck on the back of
the house of Mr Antia's father. Mrs Antia is not very strong these days. She has
not had a regular job for the past four years.
Mr Antia is a fisherman. He has not been very successful with
his fishing lately. Now he spends several months at a time working in the city
as a daily paid labourer. The small amount of money he brings back from the city
is hardly enough to feed the family. In fact the children are all underweight
Mr and Mrs Antia discuss their problems with a health worker.
These are some of the needs they mention:
- A bigger place to live in.
- More money.
job for Mrs Antia.
- Skills for Mr Antia so that he can get a better
- Food for the children.
- Medicine for the children.
and rest for Mrs Antia.
- A way to stop the family growing in size.
clothing so that other villagers will respect the family.
- A radio for Mrs
Antia, to relieve her loneliness.
At first some of these needs clearly seem more important than
others, but priorities cannot be chosen only on what seems or feels right. There
must be a reason for the choice. Below are four questions that can help people
see their problems more clearly and make their choice of priorities easier. Note
that during discussion people will come to realize that many of their needs are
related. Satisfying a priority need may in fact solve many other problems as
Which is the most serious problem?
For the Antia family, lack of food may be the most serious
problem. Poorly fed children will be susceptible to many diseases which may
handicap them for the rest of their lives.
Where does the greatest future benefit lie?
Concern is not only for temporarily solving problems today, but
for making the future brighter. Providing Mr Antia with skills so that he could
get a better-paid job would give benefit now and in the future.
What needs can be met with the resources available?
family has little money, and Mrs Antia is unlikely to get a job now. With their
existing resources they probably cannot afford new clothes and a radio. They
cannot even afford certain foods. But, within their resources, there are
inexpensive, yet nutritious foods available at the local market.
Which are the problems of greatest concern to the people?
Mrs Antia is most interested in the radio, but both she and her
husband are interested in getting a better-paid job for Mr Antia. People are
more likely to take action to solve problems in which they have an interest than
those in which they do not. Also the more people there are who take interest,
the more likely it is that the problem can be solved.
After considering all these questions together, Mr and Mrs Antia
decided that job training for Mr Antia and buying more nutritious foods within
their present budget were their immediate priorities.
Setting priorities with communities
The same four questions should be considered at meetings in
which communities are discussing their priorities. When more people are
involved, there will be more views to consider. It may take longer to decide on
priorities than when only one or two people are concerned.
Educational games can help make clear what is involved in
setting community priorities. Such games can be played with a group of health
and community workers, with a class of high school students, or even with a
group of community leaders. An example is given below of their specific use in
helping communities to select priorities, objectives, and strategies.
A simple scenario can be developed from a case study of a small
village with many problems. Everyone who plays the game takes the role of a
village member. Each person chooses a different occupation and identity and is
asked to express his or her own opinion about which are the most important
needs, and why, and what is a priority for immediate action. As the game
progresses, it will become evident that people with different backgrounds and
opinions will see more benefit in one problem being solved than in another. This
will make the discussion lively. Around twenty is a good number for playing this
game. Of course you can create as many parts as you need, depending on the
number of people in the group.
First, slowly read to the group the story of the village. Assign
each person a role such as farmer, barber, weaver, or food-seller. Then read the
story aloud again, and read the four questions listed. Ask everyone to think
about them. The group should then have a discussion and try to agree on one or
two top priorities. People do not have to sit in a large group. They may break
into small interest groups. Some may move back and forth between groups trying
to get support for their own ideas. You should move around and listen. Remind
people about the four questions on choosing priorities (you might write them on
a board or poster, if people can read). Also remind people that meeting needs
usually costs time and money. Encourage players to find the least expensive ways
of meeting the needs with the resources available.
Allow the game to go on for about an hour. After that time, stop
the discussion even if no priorities have been chosen. Discuss with the
participants what they have learned about setting priorities. Discuss how the
group could improve its priority-setting skills.
Here is the story of Poro Village which you can use as it is or
adapt to make the village sound more like those in the area where you are
Poro is a small rural village of 300 people. It has
a big market which used to attract people from all over the surrounding area.
Unfortunately the five kilometres of dirt road leading into Poro have become
very rough. Fewer people are coming now, so business at the market is not good
and the villagers are losing money. The road needs repairing.
The closest water source is a stream two kilometres away which
dries up at certain times of year. The main town of the district, about ten
kilometres away, has a piped water supply. The residents of Poro feel that they
deserve the same.
The nearest school to Poro is in another village reached by a
path through the forest. Children using the path have been bitten by snakes and
injured through tripping over fallen trees. People in Poro want their own
The nearest health centre is in the main town. This is far to
travel for a sick person, and the health workers who promise to visit Poro never
come. The villagers want a health centre too.
Finally, because the main town of the district has electricity,
people feel that Poro should have electricity too. This would help their
children study and make life at night more interesting.
Here are some of the roles people can play: farmer, carpenter,
baker, weaver, potter, tailor, trader, seamstress, food seller, religious
leader, chief (or political leader), bicycle repairer, mason, herbalist,
shopkeeper, midwife, housewife.
If at the beginning of a programme people have a clear idea of
what they want, by the end of the programme they will know if they have
succeeded. An objective is exactly what people want to see achieved by the end
of the programme.
The result of a primary health care programme should be an
improvement in the people's health. For example, if measles is a serious problem
in a community, a programme to solve the problem might have the following as its
- Fewer children will get measles.
- Those who do
get measles will recover quickly and suffer no disabilities.
- No children
will die from measles.
Since people's behavior affects their health, there will be
certain actions that people must carry out to solve their health problems.
Such actions are the educational objectives of a programme. Here
are some examples of educational objectives for a programme against measles:
- Mothers will bring their children for
- Mothers whose children get measles will bring them quickly to
the health worker for care.
- To prevent blindness, mothers will keep children who have
measles in a darkened room and make sure that they rest.
- Children who get measles will be fed as well as possible to
help them recover more quickly.
Participation in setting objectives
The individuals, groups, or communities with whom you are
working should be encouraged to select their own objectives and receive guidance
on doing so. This is only reasonable, since they are the ones who are
experiencing a problem.
When people set their own objectives, it is more likely that the
health behavior they decide upon will fit with the local culture and available
resources. As a guide, the role of the health worker is always to encourage
people to examine and discuss the feasibility of the objectives, in other words
whether the objectives chosen are likely to be achieved.
It may be some months before the results of activities can be
seen. Remind people of this so that they are not disappointed if things haven't
changed as soon as the initial action is finished.
Some factors in success
Looking at existing alternative practices is one way of ensuring
a successful outcome. Supposing that a group of mothers want their children to
grow bigger and healthier. As part of a balanced diet they would need to include
enough protein foods. There are many alternative forms of protein that they can
include in the normal diet: beans, meat, groundnuts, milk, seeds, cheese,
chicken, fish, snails, and certain insects.
A health worker could guide the mothers in their choice by
asking questions like: At what times of the year are these different foods
available'? What is the price of these foods? Is it against local beliefs for
children to eat any of these foods? Can these foods be easily prepared by the
mothers? Which of the foods do children actually like? Through such a
discussion, feasible objectives could be set regarding exactly what foods
mothers should try to give their children.
You have probably realized that, for the mothers to achieve
their objectives, other people must also act. Perhaps fathers will have to
provide money. Perhaps mothers-in-law will have to be convinced. Farmers are
also involved: the ministry of agriculture may have to provide loans and expert
advice to local farmers producing the food. The Ministry of Labour or Social
Development may have to help mothers and fathers find better ways to earn money
so that they can buy food. Objectives need to be set at the individual,
community, and national level, because all must play their part.
The steps to take to achieve objectives
Decisions on what steps to take that is on the most appropriate
'strategy' will be based on the different reasons behind behavior that causes
health problems. It will also take other factors into consideration, such as the
local culture, economic problems, etc.
The chart below explains this idea. It includes suggestions for
educational methods, that will be discussed in detail in Chapter 7. Some of the
methods are also discussed briefly in this chapter and in Chapters 5 and 6.
Since problems often have several causes, it may be necessary to
use different strategies in a programme. Also note that although certain
educational methods are listed next to certain types of action, they can also be
used with others. However, some methods work better with one type of problem
than with another.
Type of action needed (strategy)
Possible educational methods
Lack of knowledge
Posters, radio, press, talks, displays
Influence of other people
Discussion groups, clubs; family counselling
Lack of skills
Demonstrations, case studies, educational games
Lack of resources
Community surveys, community meeting, resource linking
Conflict with values
Clarification of values
Role-playing, educational games, stories