Health by the people, again? The lost lessons of Alma-Ata in a community health worker programme in Zambia

Randomized Controlled Trials (RCTs) are increasingly popular in the social sciences, not only in medicine. We argue that the lay public, and sometimes researchers, put too much trust in RCTs over other methods of investigation. Contrary to frequent claims in the applied literature, randomization does not equalize everything other than the treatment in the treatment and control groups, it does not automatically deliver a precise estimate of the average treatment effect (ATE), and it does not relieve us of the need to think about (observed or unobserved) covariates. Finding out whether an estimate was generated by chance is more difficult than commonly believed. At best, an RCT yields an unbiased estimate, but this property is of limited practical value. Even then, estimates apply only to the sample selected for the trial, often no more than a convenience sample, and justification is required to extend the results to other groups, including any population to which the trial sample belongs, or to any individual, including an individual in the trial. Demanding ‘external validity’ is unhelpful because it expects too much of an RCT while undervaluing its potential contribution. RCTs do indeed require minimal assumptions and can operate with little prior knowledge. This is an advantage when persuading distrustful audiences, but it is a disadvantage for cumulative scientific progress, where prior knowledge should be built upon, not discarded. RCTs can play a role in building scientific knowledge and useful predictions but they can only do so as part of a cumulative program, combining with other methods, including conceptual and theoretical development, to discover not ‘what works’, but ‘why things work’.

The year 2008 marked the 30 year anniversary of Primary Health Care, the health policy of all member nations of the WHO. Community participation was one of the key principles of this policy. This article reviews the experiences of and lessons learned by policy makers, planners and programme managers in attempting to integrate community participation into their health programmes. The lessons, identified in an earlier article by the author, are still relevant today. They help to identify three reasons why integrating community participation into health programmes is so difficult. These reasons are: (1) the dominance of the bio-medical paradigm as the main planning tool for programmes, leading to the view of community participation as an intervention; (2) the lack of in-depth analysis of the perceptions of community members regarding the use of community health workers; and (3) the propensity to use a framework that limits investigation into what works, why and how in community participation in health programmes. Despite these challenges, evidence suggests that community participation has contributed to health improvements at the local level, particularly in poor communities, and will continue to be relevant to programme professionals.