Submitted in Partial Fulfillment Degree of Doctor of Philosophy at the January, 1970 Department of

420 Pages·2011·21.09 MB·English

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FROM CONSUMER PARTICIPATION
TO COMMUNITY CONTROL OF
NEIGHBORHOOD HEALTH CENTERS
by
ROBERT M. HOLLISTER
B.A., Antioch College
(1966)
Submitted in Partial Fulfillment
of the Requirements for the
Degree of Doctor of
Philosophy
at the
MASSACHUSETTS INSTITUTE OF TECHNOLOGY
January, 1970
Signature of Author.... ....... ... . .........
Department of Urban Studies and Planning January 22, 1971
Certified by. ............ . . .........
Thesis Supervisor
Accepted by. . . .
Chai rman, Grladuate Students
ABSTRACT
Title of the Thesis: From Consumer Participation to Cor-munity
Control of Neighborhood Health Centers
Name of the Author: Robert M. Hollister
Submitted to the Department of Urban Studies and
Planning in partial fulfillment of the requirement
for the degree of Doctor of Philosophy
The dissertation discusses issues of consumer participation and
community control in neighborhood health centers, focusiig on conflicts
between health providers and consumer representatives. The contending
parties are defined and an analysis presented of the benefits and
deficits of participation and control which are claimed by these oppos-
ing groups.
A set of research questions is drawn from a discussion of the
rost salient issues of participation being confronted by neighborhood
health centers and a review of the experience of citizen participation
in previous urban programs.
The questions focus upon variables of organ izational requirements
and ideological positions of the actors rather than upon variables of
the local setting in which the centers are located. They probe the
nature of the demand for consumer participation and control and its
determinants, the modes of influence available to consumers, the opera-
tional differences between participation and control, and the effects
of different stages of program development and organizational variables
on provider-consumer conflicts. Other questions focus upon issues of
formal structure vs. actual functioning of the process of oarticipa-
tion, strategies of technical assistance to consumer representative
groups, implications of participation and control for prospects for
broader social change, and the demonstration effects of participation.
A pair of case studies -- of the Denver neighborhood health
program and the reatman Health Center in St. Louis -- provide a basis
for comparing models of consumer participation and community control.
Theoretical concepts of political power and influence, recuirements
of organizational maintenance *and enhancement, and professionalism
are used to analyze the development of these two centers and their
evolving approaches to consumer participation.
Evidence from the case studies indicates that the demand for
participation and control is a complicated mixture of instrumental
and end-product goals, of associated expectations about tasks and
activities to be undertaken by consumers as well as the extent of
their authority. The modes of influence available to consumers
were severely restricted. In St. Louis, outside consultants gave
consumer representatives access to a broader range of modes; in
Denver, the consumers were forced to resort to coercive means in
trying to influence the program's development. The process of
maturation of each center was found to encourage conflict by plac-
ing a shifting set of organizational requirements on both consumers
and providers. The cases demonstrated the importance of stressing
technical assistance to consumer representatives and of entrusting
this function to an agency other than the one operating the center.
There were sizable gaps between formal structure and actual function-
ing of participation. Participation and control tended, in the
short run, to relieve outside agencies of pressures operating on
them to change, but in the long run appear to be contributing to a
significant restructuring of the political interests which determine
local and national health policies.
The dissertation concludes by stating the theoretical implica-
tions of the findings, offering suggestions for further resrearch
and speculating about the future of consumer particiration and
community control of health care services and facilities.
Name of Advisor: Bernard J. Frieden
Title of Advisor: Professor of Urban Studies and Planning
TABLE OF CONTENTS
Page
ABSTRACT
ACKNOWLEDGMENTS viii
PREFACE X
'PART I: CONSUMER PARTICIPATION AND COMMUNITY
CONTROL IN NEIGHBORHOOD HEALTH CENTERS
AND OTHER PROGRAMS 1
CHAPTER I -- INTRODUCTION 2
NEIGHBORHOOD HEALTH CENTERS 2
CONTENDING PARTIES 14
Supporters of -Greater Consumer-
Participation 16
Opponents of Greater Consumer Participation 20
BENEFITS ANTICIPATED VS. LIMITATIONS CLAIMED 26
1. Improves program content, delivery
and use 28
2. Benefits individual participants 36
3. Supports greater expenditures on health
programs for the poor 38
4. Makes programs accountable to their
clients 39
5. Fulfills democratic ideals 43
6. Reduces social and political alienation 44
7. Increasesneighborhood integration and
stability 45
8. Promotes the growth of low-income
interest groups 48
9. Equalizes the distribution of political
power 50
/CHAPTER 1I -- DEFINITIONS AND THEORETICAL CONCEPTS 52
DEFINITIONS 52
CONCEPTUAL UNDERPINNINGS 59
Political Power and Influence 59
Requirements of Organizational
Maintenance and Enhancement 68
Professionalism 71
CHAPTER III -- CITIZEN PARTICIPATION -- THE HISTORY
OF AN IDEOLOGY 73
CONTENT OF THE IDEOLOGY 77
DEVELOPMENT OF THE IDEOLOGY 82
The Experience of Federal Programs 87
CONCEPTUAL ROOTS 93
Social and Political Participation 93
Volunteering 97
COMPLEMENTARY, LINKED CONCEPTS 99
CHAPTER IV -- RESEARCH QUESTIONS 105
1. Inevitability of Politics in Neighborhood
Health Programs 107
2. Causes of Consumer Demand for Greater
Participation 108
3. Main Interests of Health Consumers and
Their Support of Innovations 110
4. Provider-Consumer Conflicts over Goals
for Participation and Control 112
5. Tasks Associated with Different Goals
for and Functions of Participation 114
6. Modes of Influence Available to Consumers 116
7. Conflicts of Consumer Participation Vs.
those Related to Community Control 118
8. Effects of Different Stages of Program
Development and Organizational Forms 119
9. Formal Structure vs. Actual Functioning
of Participation 121
10. Technical Assistance 122
11. Implications of Consumer Participation and
Control for Prospects for Broader Social
Change 123
12. Demonstration Effects of Consumer
Participation 126
PART 11: COMPARATIVE CASE STUDIES 128
CHAPTER V -- CASE STUDY STRUCTURE AND APPROACH 129
SIMILARITIES AND DIFFERENCES IN THE CASE
STUDY CONTEXTS 130
CHOICE OF RESEARCH METHODS -- WHY CASE STUDIES? 137
CHOICE OF CASES 141
CHAPTER VI -- THE DENVER NEIGHBORHOOD HEALTH PROGRAM 144
INTRODUCTION 145
The Neighborhood Health Program 145
The Community Setting 156
Health Conditions 157
Health Services and Facilities 157
Organizational Framework 158
DEVELOPMENT OF THE NEIGHBORHOOD HEALTH
PROGRAM AND CONSUMER PARTICIPATION 163
Opposition in the Medical Community 163
The Lay Advisory Board 169
The First Eastside Health Board 172
The New Eastside Health Board 190
liI
THE MODEL CITIES HEALTH COMMITTEE:
A DIFFERENT APPROACH 211
DENVER -- CHRONOLOGY OF MAJOR EVENTS 222
CHAPTER VII -- YEATMAN HEALTH CENTER, ST. LOUIS 226
INTRODUCTION 226
The Health Center 226
The Community Setting 228
Health Conditions 229
Health Services and Facilities 230
DEVELOPMENT OF THE HEALTH CENTER 231
Organizational Antecedents 231
Organizational Framework 237
Planning for the Health Center 240
OPERATING THE YEATMAN HEALTH CENTER --
PROBLEMS OF IMPLEMENTATION 259
ST. LOUIS -- CHRONOLOGY OF MAJOR EVENTS 282
CHAPTER Vill -- ANALYSIS OF THE COMPARATIVE CASES --
ANSWERS TO THE RESEARCH QUESTIONS 283
1. Inevitability of politics in Neighborhood
Health Programs 285
2. Causes of Consumer Demand for Greater
Participation 288
3. Main Interests of Health Consumers and
Their Support of Innovations 292
4. Provider-Consumer Conflicts over Goals
for Participation and Control 295
5. Tasks Associated with Different Goals
for and Functions of Participation 300
6. Modes of Influence Available to Consumers 305
7. Conflicts of Consumer Participation vs.
Those Related to Community Control 306
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8. Effects of Different Stages of Program
Development and Organizational Forms 310
9. Formal Structure vs. Actual Functioning
of Participation 320
10. Technical Assistance 322
11. Implications of Consumer Participation and
Contr4 for Prospects for Broader Social
Change 324
12. Demonstration Effects of Consumer
Participation 328
CHAPTER IX -- CONCLUSIONS 333
PRINCIPAL FINDINGS 33j
THEORETICAL IMPLICATIONS 337
SUGGESTIONS FOR FURTHER RESEARCH 340
A LOOK AHEAD 346
APPENDICES:
354
A. METHODOLOGY
STUDY PROCEDURES 354
Interviews 355
Other Materials 365
GENERALIZATION FROM THE FINDINGS 365
B. DISTINGUISHING BETWEEN CITIZEN PARTICIPATION AND
CONSUMER PARTICIPATION 367
C. DENVER -- LIST OF PRINCIPAL ACTORS AND
ORGANIZATIONS 379
D. ST. LOUIS -- LIST OF PRINCIPAL ACTORS AND
ORGANIZATIONS 381
BIBLIOGRAPHY 383
BIOGRAPHICAL NOTE 398
LIST OF TABLES
Page
TABLE VI-A 1969 NEIGHBORHOOD HEALTH PROGRAM
GRANT EXPENDITURES, BY SOURCE OF
FUNDS 148
TABLE VI-B DENVER DEPT. OF HEALTH AND HOSPITALS
TOTAL EXPENDITURES FOR 1969 AND
BUDGETED FOR 1970 149
TABLE VI-C PERCENTAGE DISTRIBUTION OF PATIENTS
BY RACIAL AND ETHNIC GROUPS 150
TABLE VI-D NEIGHBORHOOD HEALTH PROGRAM PERSONNEL
BY JOB CATEGORY 155
TABLE VI-A SELECTED DEATH RATES IN YEATMAN
COMPARED TO THE NATIONAL MEDIAN 229
LIST OF FIGURES
Page
FIG. VI-A LOCATION OF FACILITIES, NEIGHBOR-
HOOD HEALTH PROGRAM 153
FIG. VI-B ORGANIZATIONAL RELATIONSHIPS, NEIGHBOR-
HOOD HEALTH PROGRAM 159
FIG. VI-C ORGANIZATIONAL RELATIONSHIPS, MODEL
CITY MENTAL HEALTH PROGRAMS 212
FIG. VII-A HEALTH FACILITIES IN AND AROUND
THE YEATMAN DISTRICT 232
FIG. VII-B ORGANIZATIONAL RELATIONSHIPS, YEATMAN
HEALTH CENTER 236
FIG. VLL-C LINES OF AUTHORITY WITHIN THE YEATMAN
DISTRICT WITH REGARD TO THE HEALTH
CENTER 239
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