A Social Vaccine for Globalization.Full paper.

A Vaccine for Globalization:
Through People-Led Health Promotion and Community Development

2004
Produced by:
Uthaiwan Kanchanakamol, Director of The Institute for Community Empowerment, Thailand
and

The Chiang Mai Health Promotion Network
• Ban Mae Faek Mai
• Ban Mae Huk
• Ban Mae Jong
• Ban Nong Wai (Muay Thai)
• Ban Saluang
• Ban San Pa Bao
• Ban Sri Boon Ruang
• Karen Hilltribes in Ban Mae Jaem
• Karen Hilltribes in Ban Mae Pakee
• Lahu Hilltribes in Pha Hom Pok Mountain
•
Society of Lanna Healers
Research and Editorial Assistance provided by:
Jennifer A. Meyer and Timothy A. Struna

A Vaccine for Globalization

A Vaccine for Globalization:
Through People-Led Health Promotion and Community Development

ICE and the CBO’s hope that by documenting and sharing their experiences future public
health and community development initiatives can build on their achievements and learn
from their struggles.

2004
Produced by:
Uthaiwan Kanchanakamol, Director of the Institute for Community Empowerment, Thailand
And

The Chiang Mai Health Promotion Network
• Ban Mae Faek Mai
• Ban Mae Hak
• Ban Mae Jong
• Ban Nong Wai (Muay Thai)
• Ban Saloang
• Ban San Pa Bao
• Ban Sri Boon Ruang
• Karen Hilltribes in Ban Mae Jaem
• Karen Hilltribes in Ban Mae Pakee
• Lahu Hilltribes in Pha Hom Pok Mountain
• Society of Lanna Healers
Research and Editorial Assistance provided by:
Jennifer A. Meyer and Timothy A. Struna

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2


Preface and Acknowledgments

S

ince June 2001, the Chiang Mai area, Thailand, had been selected for a pilot
project in which health-care was decentralized to local governments and
community groups. Local area health-care was planned and programs implemented under
the authority of provincial health boards consisting of representatives from local
government, the communities themselves and the Ministry of Health. There was an
urgent need to prepare the communities and their representatives to effectively participate
in that new system. The participatory research project had been initiated in the year 2001,
entitled” Challenges of health in a borderless world” under the support of Fulbright New
Century Scholar program throughout the 2001-2002 grant years.
Within the broad range of research project, the critical aspect had been focused on
increasing community capacity and empowering community members to improve the
health and well-being of Chiang Mai hill tribes and low-income groups in three Thai
districts. The proposed research was participatory action in nature, aiming: to determine
how to improve implementation and effectiveness in promoting the integral development
of youth, seniors and women in Hill tribes and low income communities while increasing
community cohesion and collaboration through cultural, political, social and artistic
activities; to determine how to improve implementation and effectiveness in promoting
development of skills among sub-district administration / organization and municipality
personnel in the area of community development; to determine how to improve
implementation and effectiveness in promoting creation of community partnerships by
local actors for health promotion. This involves providing incentives, skills and strategies
to community members to enable their effective participation in designing and
implementing new autonomous health care and social service systems that meet local
needs. This was especially crucial for disadvantaged groups like the Chiang Mai HillTribes and other low-income communities.
Specifically, it was proposed that proven, effective participatory action techniques
are utilized to educate, empowers, and involves members of these communities. These
include training in the use of focus groups, Delphi methods, consensus development
through negotiation/compromise techniques, participatory planning, needs assessment
methods (with emphasis on "asset-based" methods developed by McKnight and
Kretzman) and basic program participatory evaluation techniques. In addition,
community organizations such as community hospitals, NGOs, local governmental
groups were enlisted as collaborators in this learning process. Their involvement had the
additional advantages of identifying issues early-on for discussion and resolution,
enabling coalition-building and increasing trust between the three partner groups.
In the year 2002-2003, the Thai Health Promotion Foundation provided funding for
the strengthening Chiang Mai community health promotion network and monitoring and
support for its project. The aim was to buildup a network of partners within an
atmosphere of working cooperation characterized by solidarity. It was believed that this
is partially attributable to the culture and traditions of Thai society, which are favorable
toward working to build up health, together with the fact that the state is interested in

3

health.
Our participation in this study has led to an increased awareness of the dark side
of globalization and the need to prepare the community people for building a community
and social vaccine for combating those negative consequences. We believe that the social
vaccine concept will help bring a multiplicity of perspectives and approaches to global
health challenges and might be helpful to the south in setting priorities for defining the
global health agenda in the future.
Many people helped and encouraged us as we worked on this project. First we
would like to thank all the community leaders, the brave and strong marginalized people
who led health promotion and community development path by using asset-based,
internally focused, relationship driven, including Mr. Intorn Kao-prated, Mr.Tanagorn
Phomnuchanon,Mr.Preeda Thakrow, Ms.Phongpan Sakwongdaroon, Mr.Arnan Leraman,
Mr.Adul Srisawat, Mr.Aphichart Chawwiang, Ms.Kommoon Intasit, Mr. Pa-ae Jalawpa,
Mr. Pherapong Pattanaplaiwan, Ms.Prapai Armornsak, Mr. Phrommin Boacheanbaan,
Ms.Sawart Jantalae, Mr. Sonthichai Somkate, Mr.Wasan Wiwatcharearn, Ms.Fongjan
Wan-on, Ms.Narisa Pongsopa, Mr.Boonchoo Chantarabutr, Mr.Comchan Wichairat,
Ms.Boonsri Chom-ngern, Mr.Boonmee Sangnoon, Mr. Decha Chotsooksiangwiwek,
Ms.Boosaya Kunagornswat.Pra Pongtep Techakarugo
We would like to provide special recognition to all the state and local public
health leaders who have assisted us, including Dr. Amorn Nonthasute, ex-General
Director, Thai Ministry of Health, Mr. Teerapan Techa, Ms. Nit Kao Sa-ad, Mr.Terdsak
Seur-im.
Within the academic community, we have many outstanding colleagues who have
contributed to our work in a variety of ways. They include the 30 Fulbright New Century
Scholars from all over the world especially Dr.Ilona Kickbusch from Yale University, the
distinguished scholar leader, Assistant Professor Dr. Sasitorn Chaiprasit, Associate
professor Dr.Songwut Toungratanapan, Assistant professor Vichai Wiwatkunuprakarn,
from Chiang Mai University, Professor Dr.J.M.Navia and Professor Dr.David Coombs
from University of Alabama at Birmingham.
Finally, we would like to express our sincere gratitude to the Council for
International Exchange of Scholars (CIES), The Fulbright New Century Scholar Program
(NCS), Thai Health Promotion Foundation and colleagues, especially, Ms. Sirinapa
Sathapornwachana whose tireless patient contributed this project, Mr.Chaiwa
Sitkongtang, Ms. Jennifer A. Meyer and Mr. Timothy A. S. Struna who provided the
fruitful research and editorial assistance.
Uthaiwan Kanchanakamol DDS, CDPH, MPH
Fulbright New Century Scholar 2001-02
Director, Institute of Community Empowerment (ICE), Chiang Mai, Thailand
Chiang Mai Health Promotion Coordinator 2002-03, Thai Health Promotion Foundation

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5

Abstract
In October 2001, the Institute for Community Empowerment (ICE) launched a
Participatory Action Research (PAR) project. ICE used participatory techniques and
Assets-Based Community Development (ABCD) strategies, for increasing community
capacity and empowering community members to actively engage in a newly formed
decentralized health care system. ABCD has been recognized by health and community
development professionals as a valuable alternative to the traditional needsbased/deficiency-focused approach for health programming and community
development. However, community members’ perspectives on ABCD are under
investigated, and methods for evaluating the impacts of ABCD are only beginning to be
addressed and analyzed.
The purpose of this case study was two fold; first to build a more holistic understanding
of ABCD programming by exploring community representatives’ perspectives on their
own ABCD programs.
And second to describe how 11 Community Based
Organization’s (CBO’s) developed a method to identify and evaluate social changes
within their communities by asking the question; “if the ABCD approach claims to lead
to community empowerment and self-determination, as written in the ICE program
‘Increasing Community Capacity for Health Promotion and Well Being Project’ how can
the participating CBO’s measure these potential changes in their communities?”
Information for this case study was gathered over a four month period, December 2003
through March 2004, under the direction of ICE. The methods used to gather information
were primarily qualitative including; document review, direct observation and participant
observation. Community representatives described their experiences through a series of
site visits, natural focus group discussions and semi-structured interviews.
The results from this qualitative investigation indicate that the CBO’s in this case study
expanded the standard process of building on ‘strengths’ (local assets, skills, local
resources etc.), to also include cultural traditions (local music, dance and traditional
healing methods). These cultural traditions go beyond traditional dance, health methods,
and music to encompass a shared ‘way of thinking,’ living and viewing the world. It is
here in the conservation of indigenous ways of thinking or being that we see the link to
both health (physical, mental) and the environment (physical or social community
development).
Community members mentioned frequently one of their frustrations with health and
community development programs in the past was they were limited to a specific age
group, disease group, or gender. By mobilizing communities around shared traditional
culture, in contrast to the standard approach of mobilizing around a specific problem or
disease, more community members from all age groups came together for health
promotion activities. Also, centering programs on their traditional/cultural ways of life
was consistent with how individual community members identified themselves, thus

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reinforcing their collective identity and self-esteem. Additionally, when CBO’s reached
out to local and external resources for partnership or support they did so with compelling
concepts in hand, thus leveling the playing field, or power structure.
To explore the second question, 11 CBO’s developed an evaluation method, based on the
concepts of participation and empowerment, to translate what they ‘see happening’ in
their community into ‘measurable variables and indicators’ of outcomes and impacts.
The evaluation method was developed during a series of workshops facilitated by the
director of ICE and attended by CBO representatives. Their 9-step method consisted of
identifying, clustering, categorizing, prioritizing, rating and reflecting on ‘changes’ that
had taken place within their community since they began their health promotion and
community development activities.
The evaluation was implemented in 11 different communities during a community
meeting facilitated by the director of ICE and 1-2 CBO representatives. The evaluation
provided quantitative information by using a number scale from 1 - 7 to rate each
identified change, and qualitative information by including community member
comments related to each rating.
The results of the 9 - step evaluation will be used by the CBO’s to supplement
quantitative reports submitted to funders to show evidence of the broad social changes
taking place in their communities. Secondly, the stories shared by community members
to define each significant change will be used to assist in the design and implementation
of future health promotion programs. Thirdly, the 9 - step method developed by the
CBO’s during workshops will be incorporated into a facilitator guide produced by ICE to
assist in conducting future workshops and evaluations.
This case study concludes there is evidence from the perspective of community
representatives that supports the utility of an ABCD strategy for community development
and health promotion. This observation also reflected the main themes revealed through
qualitative data analysis (community pride, traditional culture, freedom, community
dialogue, and community power). In addition, the self-identification and definition of
community changes; unity, local wisdom, warmth, etc., elicited through the facilitation of
community dialogue during each evaluation, reinforces the theory and adds to the
conclusion that when community members develop and evaluate their own health
promotion initiatives there is a stronger chance for sustainable community growth,
motivation for future health promotion efforts, and the creation of self-sustaining capacity
building initiatives. The director of ICE, Dr. Uthaiwan Kanchanakamol commented on
these phenomena and explained that by practicing health promotion and community
development through the conservation of indigenous knowledge and traditions the CBO’s
are effectively creating a ‘vaccine against the ill-effects of globalization.’

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TABLE OF CONTENTS
Preface and Acknowledgments
Abstract
Table of Contents
List of Figures
List of Tables
Glossary

2
5
8
9
10
11

Chapter I: Introduction
Thailand
Chiang Mai
ICE, Thai Health, and the Network
Purpose of Study

12
13
14
14
19

Chapter II: Literature Review
Community
Participation
Empowerment
ABCD
Appreciative Inquiry
Educational Pedagogy
Participatory Evaluation
Empowerment Evaluation

21
22
22
23
24
26
27
27
29

Chapter III: Community Perspectives

32

Chapter IV: Evaluating Social Change

55

Chapter V: Limitations
Chapter VI: Conclusions and Recommendations

89
92

References
Additional Resources
Appendix A: ICE Proposal
Appendix B: Overview of Project Operations
Appendix C: Example of Semi-Structured Interview
Appendix D: ICE User-guide
Appendix E: CBO Quantitative Evaluation Results
Appendix F: Time-Line

96
100
108
116
123
125
146
156

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LIST OF FIGURES

Figure Number

Page

1. Mae Chaem Rehabilitation and Development of Herbal Medicine Group
Variables of Community Change – Star Plot

73

Indicators of Coordination – Star Plot

76

3. Frequency Graph
Summary of all identified ‘variables’

85

9

LIST OF TABLES

Table Number

Page

1. Results of Step 1 – Step 5

65

2. Results of Step 6

69

3. Results of Step 7

70

4. Results of Step 8: Variables of Community Change and Central Tendencies

73

5. Cooperation Breakdown

74

6. Indicators of Cooperation

75

Indicators of Coordination – Central Tendencies

76

8. Pile Sort 1

78

9. Pile Sort 2

79

10. Table of ‘Sorted Variables’

81

11. Types of Community Development Approaches

102

12. Qualitative Inquiry Activities

103

13. Themes and Illustrations

104

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GLOSSARY
ABCD:
AI:
CBO:
DDP:
GO:
ICE:
NFG:
NGO:
PAR:
PHC:
PRA:
SAO:
SBD:
ThaiHealth:
UNAIDS:
UNICEF:
WHO/SEARO:

Assets Based Community Development
Community Based Organization
Department of Drug Prevention
Government Organization
Institute for Community Empowerment
Natural Focus Group
Non-Government Organization
Participatory Action Research
Primary Health Care
Participatory Rural Appraisal
Sub-District Administration Organization
Strength Based Development
The Thai Health Promotion Foundation
Joint United Nations Program on HIV/AIDS
United Nations Children’s Fund
World Health Organization South East Asian Regional Office

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Chapter I: Introduction

Thailand
The Thai government is a constitutional monarchy, and the country has
progressively moved towards democracy over the last thirty years. About 18% of the 62
million people in Thailand live in urban centers. Approximately 85% share a dialect of
Thai, in addition to 8% speaking Thai-Lao, found in the Northeast, and another 8%
speaking Northern Thai, commonly referred to as Lanna. Thai-Lao and Lanna share
some similarities linguistically, and in written form.

The predominant religion is

Theravada Buddhism, practiced by almost 95% of the population. The majority of
Muslim’s live in the southern region and make up the next largest religious group at 3%,
followed by Christians (1).
Health statistics include a 92+% literacy rate for both men and women, with free
compulsory education up to grade six.

Thailand is well recognized for a dramatic

reduction in their population growth from 3.1% in 1960 to about 1% today (1). At the
end of 2001, UNAIDS estimated that 1.8% of the adult population are living with
HIV/AIDS. This is one of the highest prevalence rates outside sub-Saharan Africa.
Thailand’s current health system offers universal health care through a recently
initiated policy known as the ‘30 baht program.’ Under this program, individuals can
receive any service at the local public hospital or health station for a 30 baht fee
(approximately 75 cents) (2). There is a specific list of drugs and services covered by
this program. Private medical care is also available in the provincial capitals. According
to Dr. Prawase Wasi (2000), a health care reform activist, Thailand has a sound health
care infrastructure. However, he calls for a change in the ‘ill-health orientation’ of the
disease control and prevention system to incorporate ‘good-health oriented’ systems of
health promotion as well as continued health care reforms based on improved national
health care research (3).
The government health care system is based on the Western bio-medical model.
Also officially recognized is the Aruvedic based Thai Medicine, ‘MorPatPhanThai,’ and

13

Lanna or Northern Traditional Healing based on the holistic concept of “enhancing happy
living through the spirit, the body, the community and the environment” (4).

In the

North, traditional healers are referred to as ‘MorMuang,’ and practice at the community
level. Hill tribe groups also have local healers whose practices range from Shamanism to
herbalism and massage.

Chiang Mai
Chiang Mai, known commonly as “The Rose of the North,” is located 700 Km
north of Bangkok. Northern Thailand shares borders with Burma to the west and Laos to
the east. The city of Chiang Mai is over 700 years old and was ruled by the Burmese until
1775. The provincial population is estimated at 1.6 million people, of which 160,000 live
in the capital (1).
For over two hundred years, semi-nomadic ethnic minority groups referred to as
hilltribes have lived in the mountains of the northern region and along western borders.
Currently, their combined population includes approximately 550,000 people. The Tribal
Research Institute in Chiang Mai officially recognize 10 different hilltribes however,
there may be as many as 20 (1). In terms of linguistic groupings among hilltribes, the
most common are; Tibeto-Burman (Lisu, Lahu, Akha), Karenic (they refer to themselves
as ‘Ba-Kur-Yoa’, or Garieng) and the Austro-Thai-Chinese (Hmong, Mien). The Karen
are the largest group numbering around 322,000. In these high remote areas most people
practice subsistence farming, while a small percentage engage in ‘for profit’ agriculture
and recently, tourism. The predominant religions tend to be animist or ancestral worship,
unless influenced by missionaries or Buddhism (1).

ICE, ThaiHealth, and the Network
The Institute for Community Empowerment (ICE) is a Non-Government
Organization (NGO) directed by Dr. Uthaiwan Kanchanakamol.

The organization

promotes and practices health promotion through the concepts of Assets-Based
Community Development (ABCD). Their purpose is to facilitate the internal processes
of capacity building and empowerment among local communities through teaching the

14

skills necessary to conceptualize, plan, implement, and evaluate health promotion and
community development programs. ICE works with 22 Community Based Organizations
(CBO’s) from three districts in the Chiang Mai province of Thailand. The 22 CBO’s are
located in city, suburban, and hill tribe areas all defined as low income or ‘marginalized’
communities.
In June of 2001, Chiang Mai and fifteen other provinces were selected as pilot
sites in which health care service decision making was decentralized to the local
provincial government and community groups. Decisions were to be implemented under
the authority of newly created boards consisting of members from local government,
representatives from CBO’s, and Ministry of Health officials. This national initiative
recognized the need for not only the participation of health service professionals and
local government officials, but the popular sector as well (see Appendix A).
In order to prepare local communities, especially members of marginalized
groups and women, with the skills necessary to act within this new system, ICE proposed
a Participatory Action Research (PAR) Program entitled “Increasing Community
Capacity and Empowering Community Members to Improve the Health and Well- Being
of Chiang Mai Hill Tribes and Low-income Groups in Three Thai Districts” (see
Appendix A). The ICE staff includes a director and two assistants. Most of their
operations, including a community radio station focused on health promotion and
community empowerment, are operated by volunteers. ICE’s founder and director was
influenced by years of professional academic public health experience, environmental
activism, as well as fieldwork among marginalized communities. The central themes of
ABCD, or Strength Based Development (SBD), are present in the operations at ICE,
while conceptual frameworks of the approach have been adjusted to fit the Northern Thai
context.
Unfortunately, a number of factors combined to breakdown the proposed
Provincial board development. However, ICE continued its work building partnerships
with CBO groups and assisting them in applying for health promotion program funding.
ICE continues to concentrate its energies on working with 22 local CBO’s assisting them
in moving through a relationship driven dialogue oriented process, in order to propose,

15

conduct and evaluate their own community based health promotion and development
projects. (see Appendix B)
ICE was recognized by the Thai Health Promotion Foundation as a center for
teaching community capacity building techniques, with a focus on health promotion and
community development. The Thai Health Promotion Foundation, or ThaiHealth, was
established in 2001 as a state agency. This agency was created as part of the national
health care decentralization initiative to manage and distribute ‘sin tax’ money collected
from the two percent taxation of cigarettes and alcohol. ThaiHealth was set up to
encourage, support and fund health promotion activities for public health within the
concept: “All Thai People will have a better life and can earn their living with wellbeing. This development will proceed through by the collaboration of all key factors and
a unified intension. Through this concept Thai people can live well and be happy by
relying on themselves.” (5). Operating dimensions emphasize healthy public policies,
issue-based programs, and holistic ‘setting’ approaches. According to the ThaiHealth
website, “Most of Thai people’s health problems and deaths result from their personal
misbehavior, misbeliefs and other preventable causes such as smoking, drinking alcohol
or traffic accidents.” They continue, “The World Health Organization (WHO) has
defined the aim of public health not only to eliminate diseases from human life, but also
to build up well–being for balancing the physical, spiritual and social health. Moreover,
the WHO has declared health promotion strategies through the Ottawa Charter, and
Thailand has responded by pushing the substantial movements for well–being of Thai
people. Thai Health provides catalytic funding for projects that change public values,
people’s lifestyles, and social environments” (6).

The Ottawa Charter for Health

Promotion called for renewed commitment;
1. for the development of healthy public policy, and equity advocacy in all sectors.
2. to counteract the pressures towards harmful products, resource depletion,
unhealthy living conditions, and environments, and poor nutrition; and to focus
attention on public health issues such as pollution, occupational hazards, housing
and settlements.

16

3. to respond to the health gap within and between societies, and to tackle the
inequities in health produced by the rules and practices of these societies.
4. to acknowledge people as the main health resource and find ways to support and
enable them to keep themselves, their families and friends healthy through
financial and other means, and to accept the community as the essential voice in
matters of its health, living conditions and well-being.
5. to reorient health services and their resources towards the promotion of health;
and to share power with other sectors, other disciplines and most importantly with
people themselves.
6. to recognize health and its maintenance as a major social investment and
challenge.
(Ottawa Charter link can be found at the ThaiHealth website)

The founding board of ThaiHealth was very progressive and interested in funding
local groups directly, bypassing the non-government organizations.

Thus, it was

important that these CBO’s learn to speak the language of the funder (and vice versa),
striving to bridge this standard communication disconnect. ICE receives only travel
reimbursement monies for their work from ThaiHealth, and all program operation
finances are transferred and managed directly by CBO’s. This decentralized approach
intended to give community groups the control to develop their own health promotion
programs, and to seek out the assistance of NGO’s or Government Organizations (GO’s)
to partner with, if appropriate. Prior to this paradigm shift, communities were dependent
on these NGO’s and GO’s to meet the needs of their community.
Recognizing the fundamental changes of this approach, ThaiHealth supported ICE
and its program, ‘Increasing Community Capacity for Health Promotion and Well Being
Program’. The goal of ICE’s project was to strengthen and empower communities to
meet this new challenge. ICE invited CBO members, considered to be ‘natural leaders’
of their respective communities, to attend workshops on how to conceptualize, plan and
implement local health promotion programs.

There was no financial incentive for

attending the workshops; the only incentive was knowledge. The community analysis

17

and program planning phases occurred over approximately nine months before the
CBO’s submitted proposals for funding and began implementation.
Each CBO is represented by a “natural leader,” sometimes more than one person,
and referred to throughout this document as a community representative(s).

These

leaders/representatives are not individuals who hold an official position in the community
necessarily, but they are the community members that seem to ‘get things done’. The
criteria ICE was seeking in a natural leader was someone who could;
•

Facilitate group discussions

•

Be a strong link between the community and resources

•

Stimulate participation

•

Catalyze and facilitate discussion

•

Be at ease during trainings

•

Comfortable working at the community level and

•

Effective in mediating conflict

(Personal communication with ICE director)

Beginning in late 2001, CBO representatives met for monthly workshops at ICE
to learn assets building processes and participatory action techniques. Some traveled up
to six hours one way to attend these sessions. During the first three months they learned
how to conduct assets mapping in their own communities. During the second three
month period they participated in future search conferences with local authorities from
their own communities in order to build participatory planning strategies.

CBO

representatives learned about health promotion paradigms, advocacy, mediation
strategies, team building techniques, social action strategies, and communication for
social change.

After workshops, these community representatives returned to their

community to facilitate a process with other community members in conceptualizing and
developing their own priorities, plans, methods, and budgets. During the second year
various health projects were implemented. Examples of some health initiatives include;
•

Traditional exercise groups

•

Family strengthening programs

18

•

Cultural conservation programs

•

AIDS/drug prevention programs and

•

Herbal medicine conservation, teaching, and promotion projects

During their second year, the CBO representatives and their partners formed the
Health Promotion Network of Chiang Mai, and entered their second round of program
proposals. The original participants of the workshops conducted in year one continue to
meet once a month to offer support, share their experiences and learn from each other.

Purpose of Study
The aim of this report is to present examples of people-led heath promotion and
local community development programs, in a specific cultural context, using specific
strategies. Understanding the ABCD process, from the point of view of the community,
can provide insights into how applications in other settings might be coordinated,
supported, and directed toward improving the health of entire communities.

By

describing one groups’ effort, the authors hope to shed light on how an ABCD approach
to health promotion programming is perceived by community representatives living,
learning and practicing the process in their own communities.
It is our perspective that the opinions of community representatives practicing
ABCD based programming are unheard.

By framing the problem as an under

investigated area, the results can act holistically by adding diversity to the dominance of
professional opinions about ABCD as an approach. The public health professional or
community development worker can benefit from the information presented by learning
more about how to support community based programs, and limit the difficulties
encountered for communities practicing ABCD. The other beneficiaries of this work
include ICE and the CBO’s, as the results obtained can assist in organizational and
program development, as well as lessons learned.
Despite the growing interest in evaluation, and the growing numbers of evaluation
studies, there is still a lack of firm and reliable evidence on the impacts of NGO
development projects and programs (7). The majority of evaluations focus on outputs

19

achieved and not outcomes or broad scale impacts (7). Social, ecological, and cultural
dimensions of reality have been overlooked or undervalued systematically by
development professionals (8). Ideally, an evaluation includes an examination of the
micro and macro-conditions of social, economic, and political environments in order to
understand the constraints to development and identify possible actions to remove or
lessen these constraints (9).
The need to develop an evaluation method to explore these dimensions requires
an approach that respects the extreme cultural diversity of ideas and practices to be found
around the world. The challenge comes from acknowledging that culture will influence
ones view of the world; based on the metaphor that ‘culture is a pair of glasses through
which we see the world in a particular way – where the glasses are constructed of ones
ideas, values, rules, customs, knowledge, beliefs and laws’ – thus one must critically
question the utility of universal standards of acceptability, prefabricated variables and
indicators of outcomes and impacts.
Any development activity that seeks to improve the quality of life of marginalized
people is rooted in the process of moving from a state of dis-empowered to empowered.
In terms of evaluating this ‘empowering process’ many have concluded that based on its
context specificity there is no universal model in which to measure this process (10).
ICE and 22 CBO’s located in Chiang Mai Thailand accepted the challenge of
developing a method to evaluate the potential outcomes and impacts of their ABCD
health promotion programs. This case study describes the efforts of ICE and the CBO’s
in developing, implementing and reflecting on their evaluation method and results.

20


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Chapter II: Literature Review

There is an enormous amount of information available pertaining to development,
community health, empowerment, participation, and evaluation. For the purpose of this
study, and in order to understand the approach taken by these CBO’s - key terms are
defined and a short history of their use in the field of public/international health provided.

Community
The WHO defines community as: ‘a specific group of people, often living in a
defined geographical area, who share a common culture, values and norms, and are
arranged in a social structure according to relationships which the community has
developed over a period of time. Members of a community gain their personal and social
identity by sharing common beliefs, values and norms, which have been developed by the
community in the past and may be modified in the future. Community members exhibit
some awareness of their identity as a group, and share common needs and a commitment
to meeting them’ (11).

Participation
In regards to health, participation can be defined as a right and duty of people to
be involved in decisions about activities that affect their daily lives (12). The WHO and
the United Nations Children’s Fund (UNICEF) claim that participation enables even the
very poorest sections of the community to take part in improving the health services
available to them, and thereby create a precedent for their participation in wider
community activities (12). The WHO mentions that the level of community involvement
is an important indicator in attaining Health For All (13).
The WHO declared community participation as a people’s right and duty in 1978
with the Alma Ata conference and the introduction of Primary Health Care (PHC) (12).
Although the concept of community participation is universally accepted there appears to
be a wide variety of interpretations in terms of its definition, practice, and evaluation

22

(14). It seems the more one studies the concept of participation the more elusive it
becomes (15). However, community participation might best be defined as a multidimensional concept that takes on different meanings and significance in different
settings and circumstances (16).
Experience has shown that community participation in all phases of a project or
program – including evaluation – improves the quality, effectiveness, and is extremely
important for long-term sustainability of the particular development initiative (17, 18).

Empowerment
Empowerment can be broken down into processes and outcomes. Empowerment
is an enabling process through which individuals and or communities take control over
their lives and their environment in hopes of solving their own problems (19, 20). The
essences of development are dependent on these empowering processes (20).

The

outcome of this process is empowered individuals and groups who live in an environment
that enables them to influence the path of their lives (19). Creating this environment that
frees individuals to learn, participate in, critically reflect on, and take action in
community health and development initiatives has been an elusive priority in public
health for decades (19).
The elusiveness of empowerment results from the countless factors of influence
and their presence in several areas of development; including education, health, law,
science, government and economics (19).

Additionally, ‘empowerment’ can mean

different things, at different times, to different people. It can occur at the individual,
community, and societal level. There are no fixed and final definitions of empowerment,
merely suggestions based on individual behaviors, community conditions and norms,
environmental changes, and long-term changes in population health (20).

Most

importantly, problem-solving education, called conscientisation or self-reflected critical
awareness of ones social reality and ones ability to transform this reality by collective
action – must occur from within a person – it cannot be imposed from the outside (9).

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Development Approaches and ABCD
The type of program approach in public health, community and international
development have been passionately debated for decades. Methods for achieving various
visions of a better future range from those bound by romantic idealism, to those
pragmatically focused on hard economic realism. The past several decades of traditional
top-down and trickle down development programs, have yielded dismal results (21, 22,
23). “Barring some exceptions, most development initiatives, have often increased the
vulnerability of the most vulnerable: The poor, the illiterate, the women, the children, and
the marginalized. Strident questions have been raised about development for whom, with
what purpose, through what means, and for what ends?” (24)
The dominant bio-medical approach has become systematized into local, national
and international development and public health initiatives. Often this approach refers to
the view that a community, or ‘target population,’ is lacking something, most of the time
it is ‘knowledge’ or ‘resources.’ Generally, this ‘deficiency’ orientation provides an easy
opportunity for ‘experts’ or professionals to confirm their authority, without much regard
for the practical experiences of that target group, and ignores the underlying socioeconomic and political causes of ill health (26). An alternative to this needs based
approach is the strength or assets based community development approach, which starts
with what is ‘present’ in a community (not absent), more specifically with the capacities
of its residents and builds on the natural associational base in a community (27).
An ABCD approach stands in contrast to the ‘deficiency-oriented’ approach based
on surveying ‘needs’ and ‘problems’ of communities, which often results in the building
of patron-client communities (27). “Public, private and nonprofit human service systems
often supported by university research and foundation funding, translate the programs
into local activities that teach people the nature and extent of their problems, and the
value of services as the answer to their problems” (27). In some extremes, the members
of patron-client communities begin to identify themselves as fundamentally deficient,
with needs that can only be met by outsiders.

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Other authors have echoed similar concerns in the field of International
Development.

For example, Burkey (1993) writes, “all too many development

professionals unconsciously believe that rural development will be achieved through the
efforts of government and development agencies. They do not reflect on the possibility
that sustainable rural development will only be achieved through the efforts of rural
people themselves working for the benefit of themselves, their families, and hopefully
their communities. Government and agencies can assist this process, but they cannot do
it themselves. Unfortunately, after decades of this type of paternalism (top-down) all too
many rural people have also come to believe - they have been told so many times - that
this government or that agency is going to ‘develop’ them.

The result is apathy

interspersed with small peaks of expectation as one or another new development program
comes their way. Rather than promoting development such programs have ended up
developing dependency thinking.”
Kretzmann and McKnight (1993) point out that if the problem focused approach
is the only one available to communities, there is a clear risk for the unintended side
effect of further breaking down community capacities such as, problem solving skills and
self sufficiency. Communities depend on associations with ‘experts’ instead of building
relationships locally.

This process can devalue, deconstruct and delegitimize local

wisdom, culture, and identity, by placing control outside of the community. Kretzmann
and McKnight (1993) are careful not to advocate complete rejection of the outside
resources, only a balancing of the equation by strengthening local resources and
associations.
Advocates for ABCD have increased over the last decade largely because
development workers are thirsty for an alternative to the needs-based approach (28). Part
of the attraction to ABCD is the central focus that the community can drive their own
self-reliant development by discovering and utilizing residents’ assets and resources (28).
ABCD is a response to the observation that communities are becoming passive
consumers of services instead of active problem solving citizens (27).

Mathie and

Cunningham (2002) note that perversely these institutions (GO, NGO, donors and
academic researchers) have developed a systematized interest in maintaining this patron-

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client approach. ABCD is an effort to take back and build upon a community’s wisdom
and problem solving capabilities. According to Mathie and Cunningham (2002) ABCD
relies on in five critical elements;
1. Use methods to draw out strengths and successes in a community’s shared history
as its starting point for change (as in Appreciative Inquiry).
2. Pay particular attention to the assets inherent in social relationships, as evident in
formal and informal associations and networks.
3. Active participation and empowerment (and the prevention of disempowerment)
are the basis of practice.
4. A strategy directed towards sustainable economic development that is
community-driven.
5. Rely on linkages between community level actors and macro-level actors in
public and private sectors. Foster active citizenship to ensure access to public
goods and services, and to ensure the accountability of local government. It
therefore contributes to, and benefits from, strengthened civil society.

Appreciative Inquiry (AI) is important to define because it is part of the first step
in the ABCD approach. Its’ main purpose, according to author Charles Elliot, is to find
the necessary energy for change and its two main tools are memory and imagination (28).
“According to Elliot, AI assumes that reality is socially constructed, and that language is
a vehicle for reinforcing shared meaning attributed to that reality. Communities that have
been defined by their problems (malnutrition, poverty, lack of education, corruption)
internalize this negativity.

What the appreciative approach seeks to achieve is the

transformation of a culture from one that sees itself in largely negative terms – and
therefore is inclined to become locked in its own negative construction of itself – to one
that sees itself as having within it the capacity to enrich and enhance the quality of life of
all its stakeholders – and therefore move towards this appreciative construction of itself”
(28).

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AI draws on theories of empowerment, knowledge construction, and educational
psychology regarding sources of individual and collective motivation (28). The essence
of popular education practice rests on the concepts of learning from experience and
dialogue (29). Freire (1970) argues that people have developed their own way of seeing
and understanding the world according to cultural patterns marked by the dominant
ideology. Through the process of coming together and reflecting on their lives, people
can learn about their larger socio-political, cultural and economic environments. This
combination of learning as experience and dialogue results in the development of critical
consciousness, which means a more in depth and reflective comprehension on the broad
social, cultural, political and economic conditions in which people live. It is this raised
level of consciousness that leads to group self confidence, and eventually collective
action (29).

Educational Pedagogy and Participatory Development
Similar to Freires’ educational pedagogy and liberation through critical
consciousness, participatory development also places people at the center of the process.
Participatory development is based on the premise that the people in marginalized
communities are not the target of development projects, but rather they are the ones who
determine, drive, and control the entire development process (30).

Participatory

development starts from the assumption that marginalized and low-income people better
understand the problems they face, and how to fix them (29). For an overview of the
definitions, strengths and weaknesses of four types of community development
see Table 11.

Participatory Evaluation
There is an increased emphasis and a growing recognition that the evaluation of
community-based initiatives should incorporate the participation of beneficiaries (10). In
projects where participants took the lead in all aspects of program design and
implementation, conventional evaluations were protested because the evaluations done by
outsiders failed to capture the specific meaning that the project (processes and results)

27

had for its participants (31). This dissatisfaction stimulated the movement toward a
different approach to evaluation and has been explored throughout the nineties.
Participatory evaluations are typically done by community members, project staff,
or facilitators. At its most fundamental level, it is investigative, educational and capacity
building (32). It is a transparent process of self-evaluation using simple methods adapted
to the local culture to empower local people to initiate control and take corrective action
based on findings (33). Participatory evaluation embraces the concept of giving people a
voice and placing them at the center of all stages of an evaluation process. By assessing
the intended or unintended impacts of ones’ own program there may be a greater
potential to provide a more accurate representation of the values and concerns of the
multiple groups involved in decision-making, to promote the empowerment of
marginalized groups previously left out of the process, and increase the utilization of the
evaluation results through a sense of ownership of the results (17, 32, 34, 35, 36).
There are five general interdependent and overlapping functions of participatory
evaluation; impact assessment, project management and planning, organizational
strengthening or institutional learning, understanding and negotiating stakeholder
perspectives, and public accountability (10). With regards to an impact assessment of a
program carried out under the full or joint control of local communities, the community
participates in the definition of impact indicators, selecting and building methods,
developing the questions, collecting data, analyzing data, communicating assessment
findings, and designing actions to improve the impact of future development
interventions (10).
The participatory evaluation process is in constant motion, taking paths that may
seem uncharted, and is as diverse as the number of contexts in which it is applied (32).
There are a variety of concepts, methods, and applications developed in hopes of
engaging stakeholders to participate in producing useful participatory evaluation results
(10).

The evaluation is built on the concerns, issues and problems that present

themselves through discussion, dialogue and interaction – which are considered the main
tools to active participation (9, 32). Participatory approaches require a commitment of
time and energy as conflicting perspectives can slow or stop the process. It also requires

28

a high level of trust and some consider the results less objective than traditional
evaluation as there are many barriers that could prevent the effective development of the
process – political, academic, personal, environmental, financial, and cultural to name a
few (9, 17).

Differences in opinion and confusion can occur early and often in the

evaluation process because it involves collaboration and negotiation among individuals
who may have not worked closely in the past. The effort requires patience and flexibility
in order for collective evaluation questions to take form.
One of the primary goals of a participatory evaluation is to share control of the
evaluation process, by placing control (power) in the hands of the community while
removing it from the outside evaluator (32). The premise behind participatory processes
is the progressive shift of power, with a sequence from control to empowerment (37).
The professional must talk less, dominate less, and control less, to empower and trust
others (37). Facilitating others analysis means disempowering ourselves, leading by
withdrawing, waiting while others think before they talk and act (37).
Participatory evaluations challenge conventional evaluation practices which were
founded on the tradition of scientific investigation.

Conventional or ‘top-down’

approaches to evaluation can be broadly characterized as; focused on complex procedures
to measure cost and production outputs against predetermined indicators, oriented to the
needs of funders and policy makers to determine accountability and continued funding,
seeking information that is objective, value-free, and quantifiable, and usually contracted
and conducted by outside experts seeking to maintain a distance between evaluator and
participants (10).

Arguments against the conventional evaluation includes; they are

costly, fail to involve program beneficiaries, the outside evaluator is too far removed
from the ongoing planning and implementation of development initiatives, and the
emphasis on quantitative measures tend to overshadow the qualitative information which
tend to provide a deeper understanding of outcomes and processes (10).

Empowerment Evaluation
Community empowerment and participation are the twin pillars of health
promotion and defined as a process of enabling people to increase control over and to

29

improve their health (19). Empowerment evaluation is the use of evaluation concepts and
techniques, highlighting the importance of context – social, political, and value systems –
and incorporates it into the evaluation process (38). Empowerment evaluation embraces
the concept of sustainable human development – the strengthening of individual identity
and capacities to learn, adapt, and innovate along with the acquisition and internalization
of knowledge and information – must be part of any development process (8, 9). The
process helps beneficiaries by self-consciously guiding a program, rather than solely
judging its accomplishments (10).
The theory behind an Empowerment Evaluation, as defined by Zimmerman,
focuses on processes and outcomes. As stated earlier, an empowerment process attempts
to gain control, obtain needed resources, and critically understand one’s social
environment (39). The process is empowering if it assists people in developing skills so
they can become independent problem solvers and decision makers. Empowerment
outcomes are consequences or effects of interventions designed to empower or gain
control (39).
Fettermen adds an additional theoretical foundation of empowerment evaluation;
one that is based on self-determination, defined as the ability to chart one’s own path in
life (39). The empowerment theory consists of many interconnected capabilities; the
ability to identify and express needs, to establish goals or expectations and a plan of
action to reach them; to identify resources; to make rational choices from various
alternative courses of action; to take appropriate steps to pursue objectives; to evaluate
short and long term results, including reassessing plans and expectations and taking
necessary detours; and to persist in the pursuit of goals (39). If anyone of these links
break down it can reduce the likelihood of being self-determined (39).
Empowerment evaluation has its roots in community psychology and influenced
by action research and action evaluation (38). The purpose is to produce context-specific
definitions of success to allow program or project participants to determine their own
standards (39). The empowerment evaluation embraces the concept that participants
evaluate their own action and behavior according to the standards and values of their
setting, rather than judging according to outside criteria articulated by experts from a

30

distance (40). Defining success appears to be dependent on whom you ask. The question
of ‘who measures’ results and ‘who defines’ success is the critical issue addressed with
Empowerment Evaluation (10).

31


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CHAPTER III: COMMUNITY PERSPECTIVES ON ABCD

Information presented in this section is in raw data format, including participant
observation, community discussion and natural focus group results from four different
communities. Reflections from the qualitative researcher are also included. The purpose
is to give the reader a sense or glimpse inside how community representatives think about
their programs, the ABCD approach, and how it is similar or different to other
approaches they have experiences in the past.

Methods
Qualitative methods were appropriate for eliciting perspectives from CBO
representatives (informants), and community members.

Data collection methods

included; participant observations, natural focus groups, and semi-structured interviews.
Participant observation was selected as a data collection technique in order to
engage in CBO activities, become familiar (thus reducing reactivity) and understand
more about the socio-cultural context. This process continued on a daily basis throughout
the entire three month study period.
The purpose of natural focus groups (NFG’s) was to build on what was uncovered
during participant observation.

NFG’s occurred in community settings, and I was

frequently invited to CBO representatives’ homes. The ICE director was not present
during NFG’s, in hope of achieving a more natural setting for truthful responses. Usually
elders, youth, monks or others would join our discussions, and frequently offer
unsolicited commentary.

These community visits allowed insight into how CBO

representatives interacted with their fellow community members. Four visits are profiled
to demonstrate the diversity of local settings.
Based on results of the participant observations, NFG’s and community visits,
questions for the 12 semi-structured interviews were formed. All but one of the
interviews occurred at the Expo, which was a two day event coordinated by CBO
representatives in which CBO groups presented their work, shared and exchange ideas.

33

Therefore, CBO’s that did not attend the event were not interviewed. Semi-structured
interview questions were written in English and Thai and pre-approved by the director
(see Appendix C). Prior to asking questions, I explained I was interested in learning
about their opinions regarding the process they used for building their community health
promotion programs.

Data Management, Quality and Analysis
Responses to interview questions and two NFG’s were tape recorded and
translated from Thai to English by the researcher. During the translation process unclear
or unfamiliar words were reviewed with a native speaker, and final English transcription
was reviewed by the director of ICE for clarifications. Afterwards, the transcriptions
were printed for coding by hand. Qualitative analysis was done using open coding by
two English speaking researchers. Results are presented using quotes and long narratives
in order to illustrate relationships between the data, themes elicited and remarks in the
discussion section. For a table of qualitative inquiry activities including respondents’
roles see Table 12.

Results
Participant observation
CBO representatives were observed during meetings, workshops, and when
interacting with others in their own communities.

For example, the groups were

preparing for their exhibition at the end of 2003; however a very active member heading
up the planning for this event died suddenly, about three weeks before the event. The
CBO representatives, over 22 people, worked together to select new leadership and make
group decisions about new plans for the Expo. This was a difficult time as many
members were close to this individual; he was respected, and well liked. Although some
CBO representatives were visibly upset during meetings, they successfully reorganize a
new Expo event within a six week period.
In another example, CBO representatives were in the process of reorganizing
themselves as a Network. This occurred because during the second round of funding

34

some groups had received approval for their requests, while others were denied. By
observing their reactions it was clear this was a significant blow to the group. During the
first year they had moved through the learning process together, built relationships, and
learned from each other. Now, it looked like they were breaking up into funded groups,
possibly funded groups, and non-funded groups.

They had to reach a consensus

regarding whether they would continue on as a Network, separate into clusters, or work
individually. In the end, they decided to remain together and elected a Network leader.
Group dynamics were also observed during Expo planning meetings. During
these meetings they debated the budget, organized the site and a schedule of activities.
Only one of these meetings was held at ICE, while the others were conducted at the Expo
site, in SanSai District.
During the participant observation process it was noted who was more active and
opinionated about certain issues, the researcher listened and made small talk during
coffee breaks, and started the beginnings of relationships with people. Observing the
director of ICE during these meetings was crucial for assessing how ABCD was being
facilitated. It was noted that he did a number of things very effectively. For example, he
spoke very little and never stated his point of view unless pressed by others. He spent
most of his time listening, and asking questions which kept the group focused. Often
when disagreement was upon them, he restated the question verbally or wrote the options
on a white board in order to help the group visualize what they were struggling with.
Overall, he was able to encourage dialogue by asking inquiring questions and assisted
with mediation when necessary.
Among CBO representatives some were more outspoken then others. Discussion
and decisions were conducted in a friendly professional manner. When decisions needed
to be made individuals voted by raising hands. Initiative leaders were selected through
nomination and voting. The person elected had the option of acceptance or not accepting
the position. A note taker produced meeting minutes for CBO representatives who could
not attend. Most of the time meetings were taped for assistance in writing up the
minutes. CBO representatives tended to arrive fifteen to twenty minutes late and dressed
casually.

35


Natural Focus Groups and Community Visits
There were four primary site visits in which NFG’s occurred. Selection of these
sites was dependent on invitation by the CBO representative, and the availability of
transportation. The site visits included four CBO’s:
1. Drug Prevention Demonstration Project (Rural, SanSai District), # 3 on Table 12.
2. Nong Hoi Community (Urban, Muang District), #12 on Table 12.
3. SaLuang (Rural, Hmong, Karen and low-land Thai), #11 on Table 12.
4. Karen Mae Chaem Group (Rural, Karen, Mae Chaem District), #1 on Table 12.

The following narratives are included verbatim in order to show exactly how
CBO representatives were describing what they were doing, and what was happening in
their communities. This was important for conclusions to be drawn about how ABCD
was taking place, what kind of participation was occurring, and what they thought about
the process.

After presenting the prominent results from each of the sites the

researchers’ immediate interpretations from the field are also included, and written in the
first person.

1. Drug Prevention Demonstration Project
The first site visit was attendance at a village presentation for the Bangkok Department of
Drug Prevention (DDP). This village was selected as a demonstration site because of
their success in reducing the amount of drug trafficking, drug use, and improving
prevention and rehab activities. This project was spearheaded by the village headman,
who is also the CBO representative working with ICE. On display was an impressive
wall of posters and pictures describing their activities for drug prevention. I had a chance
to eat lunch with the CBO representative, the village health worker and his coworker, and
talk with them about the project. Later, the CBO representative and the two health

36

workers addressed the representatives from DDP and community members in a common
area located in from of the CBO representatives house.

During discussions with the village headman and community health workers, they
explained there were about 208 families and 689 persons in this village. One health
worker stated, “The village leader would come to me often before this project and we
would exchange ideas about how to build a healthy community. He would go back to his
team (representatives from the youth, elderly and women’s groups) and talk it over, and
then he would come back to me with more ideas. The village leader also contacted ICE
to ask the director if he has any good programs to strengthen the community.” Here I
concluded this was a very active CBO representative who was seeking out information,
sharing it within the associational network of the community, and in the process building
relationships with internal and external resources, such as the health worker and ICE.

I asked the CBO representative if he could tell me about how his community decided to
work on drug prevention he said, “There were people in the village addicted to drugs and
selling. The community ‘team’ met to discuss the problem, where does it come from and
how to work on it.” He explained that the results of their discussions were many
activities. For example, making community rules posted on a sign explaining what
would be tolerated and what would not be tolerated in their village. They also decided to
have activities to “strengthen families.” When I asked him why he explained that the
people in the community believed drug use was becoming a problem because families
were breaking down. To counter this they decided to have an activity bringing the elders
of the community together with the children to teach them how to play traditional
instruments, thus strengthening family relationships. They also developed a system for
assisting addicts who returned to the community after incarceration or detox. This
process involved coordinating a system for returning community members to live with
someone other than their family for at least the first three months. This was an effort to
manage the tendency to fall back into old patterns and minimalize quarrel. He went on to
explain about the youth group activities, including a ‘friend’s corner,’ where the youth

37

could gather and spend time talking about drug issues with their trained peers and health
workers.

I inquired about how many people in the community were participating in project
activities and the health worker said he thought perhaps 60%. He explained, “If 60% of
the community participates then it is good enough, if there is more than we make merit.”
He also said, “You can say or write community participation, but if it is not in your heart
it won’t happen.” I asked what he thought of this project and he said, “It’s very hard
work and requires lot of meetings and discussions, but I am very happy. In my twenty
years as a health worker I have never seen anything like this.” At this comment I was
immediately struck by the sense that this health worker, who had been working at the
community level for over twenty years, thought what was going on here was different
then what he had been involved in previously. This significant statement was explored
further in each of the semi-structured interviews. Then I asked him what made this
project work here, and he said, “The health worker (referring to himself) uses common
sense, and the village leader is interested.”

During the addresses to the community members and the DDP representatives the health
worker said, “This model of community development is strong and means bringing
different groups together to work. The villagers have done this themselves with the
assistance of the community health worker to advise them on understanding the current
problem. There is no end to this process. The community does not have to wait for the
government, they can do it themselves. The villagers here are very determined and happy
for your encouragement. We are proud of how we received the money. Every group here
knows how much money there is and what they have decided to do with it. We (the health
professionals) join with the community to eat and drink and discuss all of our ideas, not
just accept orders, we can dialogue together. I am very proud we can communicate like
this. I am an assistant only to the community.” The village leader/CBO representative
echoed these words by stating, “When we meet and discuss what and how to do things we
use the words “we will try” not “you should.” I observed consistency here in what the

38

health worker and the CBO representative were telling me over lunch, and what they later
told the DDP representatives and the 200 members of the general community also in
attendance.

I inquired about the role of ICE and they explained that both the CBO representative and
the health worker attended the workshops coordinated by ICE for learning community
development facilitation skills, and how to communicate and exchange information and
ideas with other CBO groups. They went on to explain that they had raised money for
this project from the Provincial Health Promotion office, DDP, and through village
donations, thus illustrating the multiple sources of fund gathering.

I noticed with this community, independence.

For example, the CBO

representative had initially come to the health worker and ICE for “advice on how to
build a strong community.” Therefore, the capacity building instincts were already there.
They could have been quickly squashed had ICE and the health worker not possessed a
complimentary philosophy.

2. Nong Hoi Community
This community is located on the outskirts of the main city of Chiang Mai. In attendance
were two government health officers, a retired nurse, and retired teacher who help with
the project activities, two police officers and members of the youth and elderly groups.
They had just presented their work to some government officials who had already left
when our group arrived. They began with an introductory speech, delivered by the local
monk, and the CBO representative. The group was seated at a large table and had lunch
after the monk took his food, which is customary. The meeting was at the home of the
CBO representative. I was introduced as a student working with the director of ICE.

The monk began by explaining that in their community they have about 700 permanent
residents and 300 transitory residents. He spoke about the importance of working within
the three institutions of the community the temple, home and school. “The Temple is

39

very important as it is the center of moral and social development. Three years ago the
community headman was responsible for the community. Now the central government
has decentralized power, but the community is still unaware of their rights. They have no
representation. Also, three years ago drugs started to enter the community and there was
a need to help adolescents and witnesses to drug selling know what they can do. They
started to organize and promote activities, but they have no money. We try to use all
social structures in the community to get a wide picture of what was going on, and come
up with ideas to strengthen the community. We started groups for promotion of nutrition,
exercise, AIDS and drug prevention. We have a Little Doctor Competition to encourage
young people to become health promoters within their families. For example, with
mosquito prevention, we use a traditional method and have a contest for who can collect
the most (dead mosquitoes). We do this work because community members, police,
teachers and parents are closer to the villagers, and know the problems better, political
representatives only talk.”

The CBO representative then spoke, “the concept is the facilitation of bringing multiple
community groups together, and if we do this we improve the quality of life for our
community.

We study and learn about problems and solutions together through

community participation from different sectors of society. Our vision is to work together,
coordinate people, and not separate them.”

I asked if there were any problems while doing this program and the CBO representative
said, “Our community has no office for our work, we would like some money to buy land
so our children will have a place to continue conducting community activities. Also, they
(community members) didn’t know how to work together at first. They all have hearts,
but it is difficult to find time to talk together because people have different schedules. We
have to meet on Saturday or Sunday. We have to help people understand it is important
to love themselves, love their families, and love their communities, if we don’t love our
community who will?”

40

The retired teacher explained, “In Thai society we don’t have a sense of teamwork. So
now we use activities like competition (little doctor) to create a sense of belonging in our
community, maybe this will start improving.” I tried to probe further by asking how they
will know if there is a growing sense of belonging. The CBO representative responded,
“The villagers think and try to solve their own problems. When we do an activity lots of
people come to see.

Now more community members are presenting their ideas at

meetings. Before they were quiet, now they dare to share their ideas in the room. We
don’t say whether on is right or wrong, we say what everyone has to say is useful, and let
someone try their idea.

For example, in the rural areas we have natural cures,

‘oopanya’ we are sharing this knowledge to promote health. We are manufacturing a
small amount to sell.” What I learned here was that through this community dialogue
process people had the potential to engage and share their own ideas as a member of the
community. I began to wonder what prevented them from doing that before.

I asked how will they see the benefits of your work.

The CBO representative

commented, “The drug problem has stopped, but we always have to keep our eyes open.
We have observed diabetes reduction and cholesterol reduction and less depression
among the old people. For example, some of them could not walk before our group
exercise program, now they are able to do more movement. Our younger generation is
studying meditation and now they are getting better grades. The hardest part is getting
that initial financial assistance to start, and then you have to show people that you really
mean what you say you will do, and that you are really interested in improving
community health and family.

The beginning is the most difficult. We, are worried

about our future, we might get a little more money from the drug prevention department,
but what about all of our other work?” Here I observed the potential to measure the
effect of there programs based on bio-medical markers for example, blood pressure,
cholesterol levels, etc. Ironically, in the same breath the discussion turned to funding,
and concerns about sustainability of their programs.

41

Then the Monk followed up by explaining, “Number one, the community has gained
more knowledge about health, the environment and community development. Number
two, they own this problem and they know best how to solve the problem. Through good
participation they build a sense of belonging and care for each other. And three, they are
responsible as a group.”

In this community I learned that they were mobilizing resources and perspectives
from three segments of society, the temple, school and family. Building on multiple
points of view and community ideas they were selecting their own program activities.
They are excited about the results they are seeing. Some of the problems include,
funding, having space for a community center, and concerns about sustainability. How
they are going about their work is consistent with the ABCD model.

3. SaLuang
On the day I visited the SaLuang District, about a half and hour from the city of Chiang
Mai, the community was celebrating Children’s Day, a national holiday. I had a chance
to join in those activities of music, games, eating, and comedy show. Additionally, I
stayed over night with the CBO representative and his family. Upon arrival, I spoke with
one of the natural healers working in an alternative health center built alongside the
government health station, and eat lunch with the director of the health station.

The CBO representative and the natural healer explained that three groups were in their
district; low-land Lanna/Thai, and the high land tribes of Hmong and Karen. The talked
about how representatives from these groups came together to discuss ideas and resources
for a health promotion project. It turns out there is concern among these groups about
pesticide contamination. Especially, for the low land people who eat foods irrigated in
mountain run off, which they think contains high amounts of pesticides. They decided to
combine their knowledge of herbal medicines into one book for use by the community to
encourage organic growing and conservation of traditional treatments for common
ailments.

42

The CBO representative explained, “At first there was me, and our team included about
10 other people and the director of the health station, who you will meet in a little bit.
Our experiences before were always working with the communities all the time. Then we
got together and talked about our community. In our community, we saw that people
were being exposed to a lot of chemicals. Like when they eat vegetables that have been
grown with a lot of pesticides. So then we sat together and talked about what we could
do to encourage our community to use herbal medicine and plant organically. If they do
this they don’t have to take the foreign medicine, or visit the doctor at the big hospital.
Our plan was to use herbal medicine and to help ourselves so we don’t have to waste a
lot of money or gold for the price of medicine. That was our idea, and that is what we
talked about together…. The ten others are from different groups in the area; from the
local healer group in the sub district area here, and the adolescent group.” The Lanna
Healer explained, “There are lots of different groups, the village leader group, and the
elderly group, the natural healers in all villages and the Community Development
Department workers. In these statements, there is evidence of local relationship building
and community dialogue.

I asked about how they learned about ICE and the Thai Health Foundation Funding. The
CBO representative responded, “we talked for a while here and there, and then a doctor
at the health station said she has a friend who is a coordinating work with the Office of
Health Promotion who told her about the Thai Health Foundation. Our team of 4-5
came together to talk about how to put the project together so we could request funding,
We waited for 3 months for funding approval. And then we called our team of 10 people
to come together and talk. We explained we now had the funding to do this project, but it
was up to them to figure out how to do it. We had to figure out how to collect the
information about herbs from throughout the community. From the old books written on
bamboo, in the Lanna language. The old healers would write their knowledge down in
small books. ”

43

This group brought together interested community members including youth to visit
natural healers in all three areas and collect information about the plants they use and
various formulas. The CBO representative explained the steps they took for the project.
“We collected information from throughout the villages by mobilizing the adolescent
group to travel around and write down the information from all those who had any. The
next thing we did was travel to the forests in the mountains with people who knew where
to find the plants and photograph them.

After that, we brought together all the

information we had collected from all the local healers, and typed it into a computer,
then we had it printed into a book. But we did not have them printed to sell. The books
are available throughout the community at schools, temples and all the local healers
have one. We had the book printed in Thai script but here are Karen and Hmong words
included. For example, if you look here we have the name for this herb in four different
languages, Hmong, Karen, Thai, and the English scientific name.”

In addition to discussions with the CBO representative about the project, I also had the
chance to stay with him and his family and discuss his views on development. He had
many insightful comments that are worth sharing.

“The community became tired of outsiders coming in and taking information from us,
then writing something and getting famous, while not doing much for the community.
These outsiders tend to do things for a short period of time and then leave. They are not
doing the work honestly. We realized over time, that it is much better if we do it
ourselves.

If we do it ourselves we know that we are doing it for the love of the

community, and not for any other reason.”

“Outsiders think they know how to change things for the better, but we the local people
know better. It’s like trying to tell someone how to move around in their own house, it is
my house, who knows better where all the windows and doors are but me.”

44

“The only thing the community learns when programs come from the outside is to wait,
wait, wait for the next program to come and give you something. We have forgotten how
to think for ourselves.”

I asked him to comment on the ABCD approach, he said “With this approach the
community gets to use their own thinking, and the development worker becomes the
coordinator. Often the weakness in the community is that they have lots of ideas, but
don’t know how to coordinate things to make it happen.”

“One of the problems with the way things were done in the past is that when the funding
for the project ended, so did the project. With this new approach the projects don’t end
with the funding cycle. The project will continue because community members came up
with the idea, they believe in it and will try to find money from other sources, maybe even
locally. I think this would be the best way anyway, if the money came from local
sources.”

I asked him “when you get money from outsider funders like in Bangkok or other
countries, what do they want to see in evaluations?” He said “We usually have to do an
evaluation that follows this long process and ends up not meaning very much to the
community. It is very confusing for us and very difficult trying to give them what they
want. I think it is better to evaluate a project using the communities own words, very
simply and summarize easily. That is how I do my evaluations. Sometimes I have to
explain to the funder why this is important for the community, and I make them
understand before I get money that they will get this type of evaluation. Sometimes I feel
if we meet half way, 50% what they want and 50% what the community wants that is
usually the best.”
“When doing a community project we have to be careful about 2 things: 1. who we get
the money from, and 2. what kinds of rule or limits with they make that might impact the
freedom we need to make the project appropriate for our own community. When they get

45

money from far away, follow up is difficult. To call Bangkok can cost 100-200 baht per
phone call, and that is a lot of money for rural people.”

He explained that when he found out that the Thai Health Promotion Foundation did not
have their names on the list for next year he and seven other representatives from
different Chiang Mai CBO groups went to Bangkok to, “pound our fists on his desk” and
talk with the health promotion representative for 2-3 hours. We had to, “make him
understand what and why we were doing things this way, and to show the benefits of this
kind of work. I told him he has never even been to our community to see whether or not
the program has been beneficial or not, so he can’t pass judgment on it without even
visiting once.” He explained that later they heard the proposals for 8 groups have passed
the first tier for approval, now they are waiting for final approval.

“In the past the government in Bangkok would write a program and tell us the top
priorities. We did not have any freedom in what to work on or how to do things and this
is a very limiting approach to working in our community. Now, the communities are
writing the programs and sending the proposals to the government which allows for
much greater possibilities in terms of projects.”

I asked him this new way of doing things works better then the old way of doing things.
He said, “this new way works ‘because we see it’, and we don’t have to wait around for
someone to do it for us.”

Based on our discussions, it appears this CBO representative and community
members are critically reflecting on their social assets, how to mobilize them, as well as
weighing the pros and cons of the different approaches to community development.
During this site visit I was able to capture more about how this CBO was operating in the
community, how they viewed their roles, how they thought the ABCD process was
affecting their community. For example, the CBO representative explained that because
the three different groups (low-land Lanna, Hmong and Karen) came together to work on

46

this project together, members of the high land groups are much more likely to come
down and join in community events these days.

The statement, “this new way works

because we see it” implored me to wonder what else he meant, and how he could
illustrate to others the changes they were seeing. Additional awareness was raised about
the concept of freedom, and it became more obvious how adapting projects locally is
crucial to community success.

The issue of passivity vs. pro-activity was also

prominent. For example, “we don’t have to wait around for someone to do it for us.”
Sustainability issues were explored in the statements, “One of the problems with the way
things were done in the past is that when the funding for the project ended, so did the
project. With this new approach the projects don’t end with the funding cycle. The
project will continue because community members came up with the idea, they believe in
it and will try to find money from other sources, maybe even locally.”

4. Mae Chaem - Karen Group
This village is located about five hours from the main provincial city. I was
invited to visit during the Christmas Holidays. The missionaries were active among the
Karen groups and in this village and they had a mass attended by 100-150 people. After
a community breakfast on Christmas day, I visited the CBO representative’s house, and
served tea. I was joined by a few other community members including 3 elderly men, 3
adult men and two adult women. Their roles in the village were not identified, but they
knew about the work of the health promotion program. The conversation was tape
recorded and resembled a natural focus group. I did not have any specific questions
prepared, and I didn’t anticipate the discussion to include 10 people. The Karen speak
their own language when talking to each other. Most of the men can speak Thai, and
some women. Young people of both sexes have been schooled in Thai and shift easily
back and forth. I asked questions in Thai and they were translated into Karen by one of
the adult men. In this setting I learned how they viewed ABCD, how it compared to
other health promotion work they had seen in community, how they viewed their medical
system, and the health status of their own community. The health promotion program in

47

this community was centered on restoring and promoting native Karen wisdom about
herbal medicine.

In their view, the predominant mode of treatment for forest people is herbal medicine
cures that have been passed down from generation to generation. They commented that
western medicine came from the missionaries, and when the roads came people tried to
get the medicine from the ‘doctors’ at the government health stations, “Most of the time
they (their elders) would find herbal medicine in the mountains, they would boil the herbs
and use the Karen knowledge because most of the time the doctors in Chiang Mai don’t
come here. In the past for our parents, aunts and uncles, the roads did not reach here,
they couldn’t get here. It was very inconvenient… When people died they thought it was
because of a spirit (‘rok pee’) had entered their body and killed them.

About two years ago the government health stations arrived and one young man
commented, “The patients should have enough medicine to cure their disease, but it is
not enough. By the time they need it the medicine has expired, like 6 mo or 10 mo or 2
years past expiration. That is one of the problems. They use medicine that has already
expired and it does not cure them. These days’ things are a little better, but the villagers
still need to use herbal medicine to supplement, a lot.”

In regards to the development of the program the CBO representative said they wanted
to, “improve the community by looking after the culture through the conservation of
herbal knowledge.” The CBO representative explained, “Using the medicine from the
hospital, it’s good, but there are side effects. If you take too much you have a problem, if
you don’t take enough you won’t get the curing effect of the medicine. In the past our
relatives used herbal medicine and they survived, and didn’t need to go to the hospital.
So for kids these days if they have a swelling or a cold and take the hospital medicine
sometimes they have problems. But with herbal medicine you can take a lot and it won’t
cause harm…. for our lives maybe we can use our local knowledge to teach our children
about herbs, massage, and poultices, ,,,we already have these true medicines, we don’t

48

have to buy them or go to the hospital. Why do we have to do that? So, that is how this
project got started.” He went on, “what can we do is make sure that the next generation
knows how to use and conserve the herbal medicine cures that we used in the past.
Before we didn’t have any hospitals around here or any doctors, and we survived, we
didn’t die, sometimes we died if it was a very difficult disease, or if we didn’t treat it in
time, but for treating common disease, coughs, colds, sore throats, headaches, and
rashes, we can use what we have always used…,”

I asked how this program was similar or different from others, one man stated, “It is like
this, the state programs are only interested in the outputs of their work. If they come and
test us they come once, this is not sustainable or useful. It is because the staff person is
only interested in the output of the work, not interested in the sustainability of the
program. But this type of program was concerned in doing whatever you want just
please make it beneficial, and please make it sustainable in the community. It is different
because there is much more freedom.

If it was a state program there would be many

limits and rules, and after the program it would be over, because the staff is only
interested in the outputs of the project, and not interesting giving too much else. After the
program it would end.” He continued, “If I look at the big picture, the state works health
programs and then it is up to the staff person to implement the program for the
community…But, in terms of herbal medicine, I think that if we have knowledge about
herbal medicine it is good, because you can take care of yourself, this is much better then
waiting for some worker to come take care of you.”

I asked them to talk about how they thought this project was affecting their community.
At this the CBO representative said, “We see the villagers helping themselves, they don’t
have to always go to the health station, they know the plants and they know how to use
them. The students know. They don’t have to go to the hospitals and take the poisonous
medicine. We also see the students teaching other students. For example, if one of their
friends has a headache they show them which plant to use and how to make it.”

49

Form this site visit it started to become clearer how critical cultural identity was
for their programs. Not only were CBO’s moving and mobilizing local social assets in
the form of native wisdom, they were developing associations with other communities
through the vehicle of health promotion program for herbal medicine conservation. They
were engaging in community dialogue and discussion right there in front of me! There
were many breaks in the discussion in which different people disagreed with what
another was saying. The disagreement didn’t cause uproar or chaos, instead it appeared
to stimulate more dialogue. Most importantly, they were reaching back to their own
cultural identities and building from there.

Semi-Structured Interviews
12 semi- structured interviews were conducted with CBO representatives. After
analysis, re-reading and coding of transcripts, themes became salient and are presented in
Table 13.
In addition to the themes presented, a list of concepts that representative’s
mentioned during interviews regarding what they thought helped to make their programs
work, and what made them difficult was formed. These questions were asked directly
during the interview. Included in these lists are concepts mentioned by more than one
CBO representatives.

50

Issues that made ABCD for health promotion work:
1) The ability to think and do for oneself
2) Groups decision making
3) Multiple activities under one project
4) Having those activities firmly fixed in native culture/community identity
5) Inclusion of all age groups
6) Funding and support from local and external resources

Difficulties of ABCD for health promotion:
1) Time
2) Communication
3) Group Decision Making
4) “Spoiled” by standard Development Approaches
5) Program Writing and Evaluation

One of the most frequently sited difficulties was the issue of time. Any effort to
gather community people together for community discussion was difficult secondary to
schedules, jobs, and family responsibilities. Other difficulties included communication.
Many communities were very far from the provincial center and ICE. Making phone
calls is very expensive and transportation can be long, uncomfortable, and costly.
Practicing mediation and consensus in decision making was also mentioned. The process
of reaching consensus and conclusions can be difficult if there were varied views among
community members.

The issue of evaluation came up more than once.

Some

representatives commented that they were interested in knowing more about evaluation.
There was frustration expressed over not being able to explain or show funders the “good
things” their programs were doing in their communities. The uncertainty of funding
resources was another major difficulty mentioned since the announcements of which
groups were funded and which were not was occurred prior to the expo.
Another representative expressed the “conditioning of NGO’s” as a difficulty to
over come. He noted in his community, “they are spoiled by the NGO, so all they

51

(community members) know is how to do is spend money.” By practicing ABCD they
“have to learn how to plan, report and evaluate their work.” He also mentioned that the
project ideas and activities were too big and there was not enough leadership, negotiation
strategies or skills among the group members. In the same case there was concern about
the ideas for activities coming from only one or two people instead of a community
group. Interestingly, the individual in the representative position for this CBO has a long
30 year history in the NGO field. He sited himself as a difficulty, because of his NGO
training, and was planning to remove the difficulty by removing himself from the CBO
representative position.

Discussion
The information elicited from the semi-structured interviews was consistent with
the information drawn from participant observation and the NFG’s. The semi-structured
interviews were useful for ICE in terms of citing weaknesses and strengths of the process.
The NFG’s and participant observations provided more in-depth information related to
socio-cultural context and insider perspectives.
Some initial assumptions were confirmed in the data and support its validity. The
consistent statements from community representatives, “we did it ourselves,” “it was the
ideas of the villagers,” “we are proud” and “they are proud of themselves” provide
convergence when triangulated with ABCD methods, and the theories of selfactualization and self-sufficiency (41, 42). Based on the principles of ABCD and the
theoretical constructs of educational psychology, self-efficacy, and empowerment, the
themes generated from the semi-structured interviews are also consistent and
confirmatory.
The primacy of traditional culture and cultural identity appear to be critical pieces
of CBO program building, and provide evidence of a difference between the ABCD
processes as described by Kretzmann and McKnight, and the process being supported by
ICE.

Kretzmann and McKnight emphasize the mobilization of resources (capacities,

skills) and local relationship building. In this cases study there is evidence of resource
mobilization and local relationship building, with the explicit emphasis of traditional

52

culture as strength through which health promotion and community development are
taking place. Based on this observation, I believe what is happening among the groups in
this case study may be even stronger than the ‘standard’ ABCD approach. CBO’s are
conserving indigenous knowledge and traditions through health promotion and
community development programs, therefore preventing the identity destroying aspects
of rapid growth. As the director of ICE often stated, “what they (CBO’s) are doing is a
vaccine against the ill-effects of globalization.”
Additionally, by expanding the process of building on ‘strengths’ (local assets,
skills etc.) to also include cultural traditions (local music, dance, traditional healing
methods) this allowed CBO’s to reach out to local and external resources with something
compelling in hand, thus leveling the playing field, or power structure.

Therefore,

through the ABCD approach, as practiced here, there was a better chance for more equal
partnerships between CBO’s and local and external associations. Mobilizing around
traditional culture brought more people together, from all age groups, since the focus was
not on a specific problem or a disease. Centering on traditional ways of life was also
more in line with how the community, and individuals, identified themselves, thus
reinforcing their collective identity and self-esteem.
These inferences were based on the interpretation of how CBO representatives
and community members described themselves, or in other words, an ‘emic’ perspectives
of their own community.

Although these groups are considered ‘marginalized’ by

professional development standards (based on income access to resources, education
etc.), when they described their communities, none described themselves as poor, weak,
impoverished, or through a list of problems. For example, “we are Karen, we live like
Karen, we live comfortably” or another “we are a typical Thai community, and the
environment is good because we live out in the countryside” or “our community is in a
rural are and we live using the rural ways of life.” A similar phenomenon occurred
when trying to investigate community identified health problems.

I often asked

community members to tell me what kinds of health problems there were, and most
frequently they responded by stating “we don’t have any.” This was also confirmed in

53

A Social Vaccine for Globalization.Full paper.

A Social Vaccine for Globalization.Full paper.

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