Introduction

1In 1989, the Republic of Benin was facing a great social and economical crisis. Civil servants of all the sectors in public administration were on strike. People did not know where to go for their health care. Salaries were not paid for more than six months and life for the general population was very difficult. The country was about to degenerate into civil war as a result of the civil unrest in the country.

2Thanks to the assistance from the French, and Canadian and American Mennonite missionaries, the Bethesda Health Centre was started in 1990 with US$ 1,000 granted by theses partners. Today, the Health Centre of Bethesda has expanded and has become a large Hospital in Cotonou. It hosts each year about 100,000 patients and has developed the department of paediatrics, ophthalmology, stomatology, cardiology, obstetrical gynaecology, X-rays, etc. The Hospital has also put in place an AIDS service which has been promoted by the government to the status of an AIDS Treatment Centre.

3In an integrated vision, Bethesda has established other departments. In 1993, the Sanitation department was established to implement sanitation and environmentally-friendly projects aimed at reducing the high incidence of some diseases frequently treated at the hospital. In 1996, the decision was made to establish a micro-finance department called PEBCo. This initiative, which currently has 10,000 clients, uses community savings to promote income-generating activities. Since many women were obliged to use the loans for family needs (health care, children schooling, etc.), they were unable to reimburse them as planned. Hence the Bethesda non-government organization (NGO) recently began an initiative to provide a community-based health insurance option for the population in 2006.  There are now 12,000 members. This paper focuses on the presentation of Benin and the program, but also describes how the project could be better improved and what were its benefits and impacts.

The Purpose of the Project

Presentation of Benin

4Benin is a West African country of nearly seven million inhabitants and has a high proportion of young people. About 45 per cent of the people live in urban areas, and this is nearly ten per cent higher than the level of urbanization in sub-Saharan Africa as a whole. Politically, Benin has been stable for about 19 years and is governed under a democratic system where individual freedom is respected. The government has been following a policy of decentralization for about the past 6 years. Since then, the population has been content to build its future, and peace has made the country a dynamic region. This has contributed to a considerable increase in the rate of urbanization in recent years. As a result, urban issues have increased in prominence in the policy and practice arenas.

Presentation of the program

5In early 1990s, Benin was trying to overcome political, economic and social crisis. Fortunately bloodshed was avoided and a democratic government was adopted for the country after the National Conference in 1990. This crisis severely limited the level of services that the city authority of Cotonou could provide to its citizens. The public hospital was not functioning properly and the few private health care options were very expensive. The poor could not afford private care. Thanks to the assistance from the French, Canadian and American Mennonite missionaries, the Beninese evangelical churches founded the Bethesda Health Centre in 1990. When the Bethesda Health Centre started operating in Sainte Rita in 1990, many people, estimated as high as 55% of the population, were experiencing illnesses, particularly gastroenteritis, malaria, and bronchial pneumonia. During the first few years, the number of cases treated by the centre doubled each year. Many people were returning to the centre repeatedly with the same illnesses. The casual dumping of waste was undoubtedly a contributing factor to the high levels of illness. This was a problem that needed to be addressed urgently. In general, the living conditions of many people in the area were the cause of their bad health.

6At that time the city’s waste management department had only three working trucks that it could use to collect rubbish from the city with approximately 700,000 residents.The dumping of rubbish was a big problem in Cotonou. Rubbish was dumped in the streets, where it accumulated in large holes that had been worn away in the surface, on open ground, near to houses, in the canals and the marine lagoon surrounding the north side of the city. The mere establishment of a clinic in the community where there were very poor sanitation conditions did not accurately address the health issues of vulnerable people. To raise awareness among the community about the links between poor health and lack of proper waste management and inadequate sanitation, the health centre created a unit for community development and environmental protection (DCAM). This was successful at making contact with communities and in promoting the need for environmental action to improve health. The community had then become a willing partner for seeing that action would be taken.

7The environmental programme started then around the clinic in the district of Sainte Rita, one of the 13 local authority districts that make up the city of Cotonou. This district has a population of approximately 40,000 and occupies three square kilometres. About half of this site is low ground that experiences yearly flooding.

How the project was implemented

Planning, Preparation and Piloting

8In 1993 DCAM Bethesda undertook the initiative to bring together representatives of the community, government and the local authorities with a view to taking action to alleviate the chronic problem of rubbish dumping. Some members of the local authority were initially skeptical and did not believe that it would be possible to convince people from the local communities to contribute towards clearing away the rubbish. DCAM also met numerous times with groups and organizations, such as women’s and youth groups, older people, church organizations, market traders and school and parent representatives, from the community, as well as with the service providers themselves. Gradually a consensus was established on the needs, objectives and priorities for action and what each of the stakeholders could contribute or offer.

9It was decided that the priority would be to develop a sustainable waste management system for the neighborhoods of Sainte Rita. Sustainability would be endorsed through building the management capacities of local organizations and training of and support to local people to develop jobs in waste collection and processing. It would also be important to bring in the local authorities and relevant government departments into the partnership so that they could share the responsibilities for waste management and contribute in their areas of management capacity, support and expertise.

10The communities were keen to start clearing rubbish from the streets almost from the outset of the discussions about the programme and also began to fill in some of the holes in the roads where the rubbish was being dumped. However, these efforts were very limited compared with the scale of the dumping in the whole area.

11Over a period of 18 months, DCAM entered into painstaking discussions with affected stakeholders to formulate a plan for dealing with the waste disposal issue throughout the whole of Sainte Rita. The main hurdles to overcome were to obtain and equip a suitable site to act as a waste collection and recycling centre, obtaining real commitment rather than tacit support for the project from the municipality in Cotonou and the environmental ministry, negotiating a formalized agreement with communities specifying how contributions to the undertaking would be shared, and securing funding for a preparatory programme geared towards full long-term sustainability.

12DCAM was able to use a site about 20 km away for its processing centre and secured funds of US$ 120,000 from the French Embassy Fund for Development (Caisse Française de Développement) to initiate waste management activities in a more systematic way. Additional funding was provided by Evangelische Entwicklungsdienst V.e (EED), a German Christian organization. This project support was endorsed by the office of the United Nations Development Programme (UNDP) in Benin and the Minister of Finance of Benin as an opportunity for more environmentally-sustainable practices in waste management in the country.

13By January 1995 everything was in place for the Programme for Sanitation and Protection of the Environment (PrAPE) to be formally inaugurated. The launch was attended by community representatives, staff of DCAM Bethesda, representatives of the French Embassy, and the Minister for the Environment as well as other relevant stakeholders.

Strengthening the Capacity

14When PrAPE started the project, the staff realized that it would require a great effort and commitment of all the stakeholders to succeed in disseminating community-based waste management in a systematic way to the majority of households in Sainte Rita. In the few areas where residents had already taken the lead and organized their own campaigns, the organizers were likely to have been highly motivated. It could not be assumed that all the residents throughout Sainte Rita would be as motivated.

15DCAM intended to continue with the promotion of environmentally-focused waste management; but at a more intense level and more extensively in the settlement. This would highlight how residents would benefit and their surroundings would be improved. Other aspects of the campaign would be important too and the whole process would be more effective if these were utilized strategically and in an integrated way. Thus, DCAM needed to find out about what products the different types of waste generated could be recycled into or reused as, what existing or potential markets could be penetrated for these products, what processing technologies were available and which of these would be the most suitable, what equipment and other material assets would be required and how all of these could be utilized by local people to obtain sustainable jobs and equipment. DCAM then would have to take the leading role in disseminating this know-how to a large number of people in Sainte Rita.

16Building local people’s confidence was a priority in the initial stages of the programme. People needed to be convinced that DCAM had the right ideas for dealing with the waste management issues and that the programme had a long-term and deeply-rooted commitment to seeing the process through to a conclusion. They also needed to know that all the waste would be taken away or reused at a cost that would be affordable to the majority of them. DCAM then would have to encourage local people to realize that the future and sustainability of the programme lay in their hands and that they had the innate skills that merely needed to be awakened and extended so that the communities could make an effective contribution.

17The small-scale waste removal activities carried out during the preliminary stages of the programme had proved to be valuable learning experiences for the larger-scale effort. In practical terms, the focus of the activities had moved onto training of community groups so that they could have a key role in putting into place sustainable mechanisms for waste management; and organization of neighbourhood committees to provide the local management capacity. The technical aspects of waste recycling and reprocessing that would be suitable for community application were developed by DCAM. Research was undertaken to find out how waste recycling was being managed in Germany, the Netherlands, Egypt and elsewhere in West Africa, amongst other countries and regions.

18During this phase, the opportunity was also taken to raise awareness among many more people in Sainte Rita about the links between their illnesses and health problems and the rubbish that was being dumped in their vicinity and the inadequate sanitation that they had access to. Many of the facilitators for these sessions were women, to encourage more women from the community to attend. The aim was that later the people taking part in these workshops would commit themselves as householders who make their waste available to the programme or as members of groups or enterprises that collect, reprocess or recycle the waste.

19The waste management department of the city of Cotonou and the Ministry of the Environment in Benin were key institutional partners of the programme. These organizations knew about the problems caused by indiscriminate waste dumping. They had had little impact in alleviating this problem themselves, especially in the lower income areas; but still needed to be convinced that an alternative, community-focused approach would be more effective. However, they were willing to support, co-operate with and learn from the programme, even to the extent that the Minister for Environment attended a number of seminal events organized by DCAM. Eventually these institutions, together with NGOs, contributed to spreading the message about DCAM to other municipalities in Benin through organizing workshops and meetings and production and dissemination of publications. Working with DCAM municipalities, they would learn what aspects of waste management they can focus on most effectively and which ones would best be taken care of by communities that have had their capacities raised.

The Scaling-up Experience

20Achieving scaling-up was not a high priority during the early stages of the programme. Most importantly the intention was to demonstrate that a significant proportion of the waste generated in the municipality of Sainte Rita could be dealt with by local people, thereby creating local jobs and incomes and contributing to environmental sustainability through recycling and re-use wherever possible.

21A number of factors contributed to successful scaling-up in Sainte Rita. These included:

• DCAM Bethesda already had extensive contacts and a good knowledge about local communities through the operation of healthcare services. The team was able to organize meetings and training with community members without significant problems.

• DCAM-Bethesda placed high emphasis on preventive healthcare rather than just treating patients with illnesses. They had therefore already acquired communication skills and the use of appropriate media for communicating with local people.

• Local people and the municipality recognized that waste dumping in the area was a problem that needed urgent attention and were willing to support any initiative that appeared to show promising results. Many community members were motivated to sort their waste at home.

• DCAM was successful in convincing many local people that many of their health problems were caused by inadequate sanitation and indiscriminate waste dumping. Apart from the physical discomfort of illness that people wanted to avoid, illnesses also often prevented people from working, and to treat them people had to attend the health centre and pay for the services.

• Communities, through their neighbourhood committees, had a high level of input into determining the direction of the programme.

• The training that was undertaken, focusing on youths, was effective in helping them to set up business as waste collectors and recyclers.

• Waste was collected from households at regular intervals, so that the levels of waste did not build up and residents had confidence in the collection service.

• The household collection service was initially subsidized and residents charged a low rate of about US$ 0.50 per month to encourage uptake. By 1999 households were being charged a more economically realistic rate of about US$ 3 per month; but residents were still willing to pay this as they appreciated the improvements in the settlements that had been achieved.

• A loans programme that was set up was successful at helping entrepreneurs setting up and acquiring tools and equipment.

• It is relatively low in cost to set up a business as waste collectors. For an outlay of about US$ 300, two people can start a business. This cost is affordable for many community members and they are further assisted in meeting these costs by the loans that are made available.

• DCAM was successful at linking entrepreneurs to markets.

• Much of the day to day operation of waste collection and promotion of waste sorting by households is overseen by neighborhood committees. DCAM does not generally become involved in this and could thus devote much of its effort to dissemination, publicity and building the capacities of communities that were at the beginning of managing their own waste products.

22Since the launch of PrAPE in 1995 in Sainte Rita, the programme has extended to much of the rest of the city of Cotonou, which now has a population of nearly one million, and several other cities and larger towns in Benin. Some different factors were important for this more extensive scaling-up than in Sainte Rita, though other factors were the same. These different factors included the following:

• The work in Sainte Rita had proved to be an effective demonstration model with other organizations in Cotonou and Benin wanting to replicate and adapt the successful outcomes of the programme in their own areas.

• The Department of Environment in Benin was a key stakeholder in the programme in Sainte Rita and took an even more proactive role in the wider dissemination. The ministry donated carts, containers and trucks to help activities so new areas could get started.

• The development of a network of NGOs and waste processors was instrumental in the dissemination process. The network first extended throughout Cotonou, incorporating 75 organizations, but more recently networking activities have been organized throughout Benin.

• DCAM was involved in the scaling-up process by providing a consultancy and advisory service to other groups and organizations wanting to set up community-based waste management. This has helped to ensure that these new operations are well run and managed.

• The loans service that was initially set up to assist waste collectors in Sainte Rita start their businesses has become a fully-fledged community bank that still focuses on loans for waste collection and processing but can also offer loans for other needs. The bank now operates in the three largest cities in Benin. The bank also offers training in business management skills so that their businesses are more likely to become successful.

• DCAM has been relatively successful at leading the NGO network and help Oxfam (Quebec)  to implement their project of capacity building of the network of NGOs and waste processors in Cotonou. The World Bank and the Government of Benin are supporting a community development and infrastructure programme, managed by DCAM, operating throughout the country.

• DCAM has employed students and interns. Some of them, as well as some former employees of DCAM, have themselves helped to set up local waste management services in other areas.

• DCAM has had good cooperation with numerous other organizations in Benin and internationally to extend the programme. These organizations have included universities, research centres, municipalities, NGOs and the government ministries.

• Waste issues were a priority that needed attention in many places in Benin, so communities, municipalities and NGOs were interested in adopting the processes that were demonstrated in Sainte Rita. They could also see that the majority of households had signed up for the waste collection service and that the service could be run as an economically viable operation.

23In addition to scaling-up geographically and in reaching large numbers of people, the programme has also scaled-up in terms of broadening the scope of its work. This aspect of scaling-up has been undertaken through:

• Recycling or land filling of suitable waste from the health centre. Eventually the programme was handling waste from 30 health centres throughout Cotonou.

• The community bank that was set up to promote women’s savings now also support the creation of other small businesses, apart from those based on waste, many of them operated by women. Most of these businesses have been in food processing.

• Assisting the government-coordinating agency (SERHAU) in promoting community participation and community-based development. This programme, set up by the government and the World Bank, is being implemented in the three largest cities of Benin. For three years PrAPE has been helping to:

• Establish neighborhood association committees,

• Develop the objectives and plan for each of them,

• Build capacity on managerial skills of the committees,

• Assist in community infrastructure building (schools, health centres, youth centres, markets, and public latrines) and prepare the community to manage them effectively.

• Build the equipment for water supply in the community.

Participants in the Process

24One of the successes of DCAM was the level to which the programme has been able to integrate the activities of many stakeholders into a dynamic that has had significant impact throughout Benin in environmental and health improvement, income generation, poverty reduction and community development. Stakeholders involved in the programme have included NGOs, community groups and organizations, municipalities, government, donors, private sector companies, researchers and consultants.

25The driving force behind DCAM was the Bethesda Health Centre (DCAM Bethesda) which was set up in Sainte Rita in1990 by Mennonite missionaries from the United States, Canada, and France, together with Benin’s churches. Bethesda established DCAM in 1993 to initially address the problems caused by uncontrolled waste disposal throughout Sainte Rita.

26Communities were the other vital partner. Without cooperation of community groups, the waste would not have been cleared away and would have continued being dumped. However many residents in the eight neighborhoods of Sainte Rita were responsive to the awareness raising meetings organized by DCAM. Neighborhood associations already existed, and as the programme developed they became more involved. DCAM also encouraged the formation of neighborhood committees that would organize the local management of waste collection and collaborated with the neighborhood associations to select participants for the committee. DCAM would then enter into a dialogue and train the committee members on waste management issues.

27Scaling-up would have been difficult without institutional support and cooperation. DCAM was able to obtain support at the start of the programme from the French Embassy and the Ministry of the Environment in Benin. Many discussions took place between DCAM Bethesda and these two institutions on programme formulation, and the Minister of the Environment and representatives from the French Embassy attended the launch of DCAM and other important events during the programme. DCAM also had discussions with municipal representatives in Cotonou, and the support to the programme of the ministry was a key factor in obtaining municipal support for the programme in Cotonou and, later on, in other towns and cities. The Ministry of Environment also provided practical support by donating carts, trucks, waste containers and gloves for the programme.

28DCAM was initially a health and environmental NGO that largely operated within Sainte Rita. However, for scaling-up of the programme in other areas of Cotonou and in other cities and towns, the cooperation and support of other NGOs that worked closely with their respective local communities was valuable. DCAM has been actively involving these NGOs through a network that comprises 75 NGOs in Cotonou. Together these NGOs employ nine hundred workers and have a budget of about US$ 900,000 per year. A national network of NGOs involved in waste management is being developed to cover the other cities and towns where community-based waste management has been set up.

29The other important stakeholders in the process are the customers for the reprocessed products from the waste. These include farmers and gardeners who make use of the compost made from the organic wastes, and residents who use the briquettes made from paper and sawdust. Particularly important was a company called Agriplas that takes about three tonnes per month of recovered plastic that has been granulated to make electrical cable, among other applications. Altogether the recycling centre that serves Cotonou produces about 100 tonnes of recycled granulated plastic waste per year. Other private companies make use of this material for a range of plastic products. The plastic waste stream is particularly valuable for the project as it is the highest value product from the waste and contributes a lot of the revenue to the operation that goes towards reduction of the amount that households are charged.

Dissemination and Communications Issues

30A strength of the programme was that the dissemination of the programme took place largely by word of mouth, and DCAM encouraged neighborhood committees and NGOs to keep residents informed and seek their views about the programme in this way. Meetings, awareness raising workshops, and training events were used to raise community awareness about the programme and issues around health, environment and waste management; and to interest residents to take part in the programme.

31Once a number of residents in an area had agreed to be part of the programme, either as waste collectors or as providers of waste that had been pre-sorted, PrAPE organized specific training and demonstrations. Neighborhood committees acted as intermediaries between residents, collectors and PrAPE and maintained ongoing informal contact with these stakeholders. More formal meetings were organized once a month between PrAPE and neighborhood committees. These provided community groups with an effective way of highlighting any problems or issues that needed to be resolved or any new developments that needed to be considered.

32Meetings were also organized with donors, the ministries of environment and health, and representatives from the municipality of Cotonou initially to obtain ideas on the scope of the programme and how these particular institutions would be involved. Other NGOs were not initially important stakeholders as the programme was focused on Sainte Rita, where many people knew about DCAM Bethesda. However, they became key stakeholders in the wider dissemination in the rest of Cotonou and more widely in Benin.

33As well as DCAM, the Ministry of Environment had a leading role in the dissemination process for scaling up the programme beyond Sainte Rita. Together they organized workshops and seminars and produced about 100 different documents and broadcasts about the programme. These, together with NGO networking, were the principal ways for dissemination of the programme in order to scale-up to the rest of Cotonou and more widely in Benin.

34Other dissemination pathways also contributed to wider dissemination of the programme. These included the actions of former interns, students and employees who worked with DCAM and then set up similar operations in their own areas; awards and competitions, for example, for young people who had made the largest contributions to environmental improvement; and the consultancy service that DCAM has provided on community and infrastructure development. A particularly visible initiative of DCAM was green planting along main roads and around prominent buildings in Cotonou. The compost used in the planters was produced from organic waste through the programme.

What Were the Benefits/Impacts of the Project?

35Bethesda has grown remarkably in only 19 years of existence from quite a modest operation in 1990 based in the eight neighborhoods in the area of Sainte Rita in Cotonou, to a programme covering environmental improvement, livelihood and income strengthening, and services and infrastructure provision in many cities and larger towns throughout Cotonou. A particular strength of the programme was the way in which DCAM was able to combine various sources of revenue to produce a process that now covers all of its costs, but is still affordable to many of the residents and can support waste collectors and the workers and operations at the recycling centre. More than 90 per cent of the households in two neighborhoods in Sainte Rita are pre-sorting their waste and having it collected through the operation. Donor and government funding is now only being used to further develop and extend the programme and not to cover existing operations. Through the efforts of DCAM, the Ministry of Environment, NGOs and other stakeholders, locally-organized waste management is now being carried out in parts of the cities and towns of Porto-novo, Parakou, Kandi, Come and Aplahoue. In addition, PrAPE has assisted other organizations elsewhere in Benin and in Togo and Congo to set up similar operations.

36The most successful examples have been in Cotonou and Kandi. In Cotonou, the recycling centre 20 miles from the city has been set up and extended with donor support.  It handles waste from 15 neighborhoods in the city. The waste collection operation in Cotonou receives revenues of about US$ 150,000 annually from households. To reduce costs of the operation, residents have been informed about reducing the amount of unsuitable waste they send for recycling or landfill. The operation in Kandi has been particularly successful, where a recycling centre has been set up close to the town and only 20 per cent of the waste from participating households is sent for land filling.

37A loans and savings operation that was started in a modest way in 1996 to support small-scale entrepreneurs in waste activities has grown very impressively. This has become a community bank with an annual turnover of about US$ 12 million and makes over US$ 2 million of loans to about 10,000 recipients per year. It operates in the three biggest cities in Benin. The bank operates without subsidy.

38DCAM has initiated a process in community-based waste management that has been scaled-up successfully throughout the city of Cotonou, other towns and cities in Benin and in a small number of other countries in Africa:

• The establishment and providing of low cost health cares (in all specialties) for poor people through the Bethesda hospital in Cotonou. The government has recognized Bethesda as an AIDS treatment Centre.

• The development of a self-funded waste collection program in the city of Cotonou and in fourteen other cities creating 2000 jobs in the country.

• Creation of a credit and savings organization called “Programme d’Epargne Crédit à Base Communautaire (PEBCo)” that reaches 15,000 people with a loan portfolio valued at US$ 2 million and a repayment rate of 95 %. The turnover amounts of US$ 10 million.

• Establishment of the Cotonou-based AGRIPLAS centers 1 and 2 to recycle plastic and paper for buyers from Nigeria.

• The economic and financial development of this social enterprise from a yearly budget of US$ 1,000 in 1990, to a current budget of US$ 3,000,000.

• Assisting the government-coordinating agency (SERHAU) in promoting community participation and community-based development. This programme, set up by the government and the World Bank, is being implemented in the three largest cities of Benin.

39For three years PrAPE has been helping to:

• Establish neighborhood association committees,

• Develop the objectives and plan for each of them,

• Build capacity on managerial skills of the committees,

• Assist in community infrastructure building (schools, health centres, youth centres, markets, and public latrines) and prepare the community to manage them effectively.

• The community health insurance in Cotonou is again an evidence of the skill of Bethesda to obtain results at community level.

• Bethesda has a training program for community health providers in order to help people in hard areas to administer the basic care for people with malaria and other diseases.

• Bethesda has implemented health care at the community level with advanced strategy  which consists of vaccination door to door  within the community.

• Bethesda has been implementing a decentralized and waste management project in eight municipalities in Benin by building their capacity to develop a good program for sanitation issues in their area.

40The work of Bethesda is beginning to be widely recognized. In 2000, the programme made the shortlist for the Dubai International Award for Best Practices - Best Practices and Local Leadership Programme. In 2002 the program won the Dubai international award for best practice.

41Bethesda has also won other international Awards:

• the Japanese Award for Most Innovative Development in January 2007 by the Global Development Network;

• The Best NGO in Africa award in 2007 by the African Social Award.

42In addition, Bethesda:  

• Has hosted the international community with visits by the American ambassador to Benin in 2007, the German ambassador to Benin in 2007, a member of the Board of Directors of the World Bank in September 2008, and the Vice President of the World Bank for Africa in October 2008.

• Is directed to public benefit organization by the government of Benin by  Presidential decree 2008-278 in May 2008.

How Could the Project be Better Improved?

43Even if the project has been very successful, it is also important to note some weaknesses that need to be addressed. The vision at the beginning was to take action in order to solve problems within the communities because people were facing hard situations. The study or research that will help to follow up the impact regarding basic data on the communities was absent. The research work is less developed and the program did not have the tool that would help to make it feasible to publish results from the work. Many findings were not pointed out through research actions; this explains why few publications have resulted from the work at Bethesda.

44Another challenge is communication, which is still very poor so many donors that may know Bethesda’s experience are not aware about the proved capacities of Bethesda to alleviate poverty with its integrated approach. Bethesda is able to help in other countries because the experience itself is very strong and can help to reduce poverty.

Conclusions

45The Integrated Health Care Program in Benin progressed over the years as community needs appeared and is based on a participatory problem-solving model. Therefore, the design has been a dynamic system that integrates new possibilities to empower the community to face problems and improve its welfare.  The initiative, which began in 1990 with a community-based approach, led us to the conclusion that to address the health problems in developing countries such as Benin, we have to look at the health care system as a whole in response to the needs of the community.

46The four-component program approach is the one that Bethesda is now carrying out to address the needs of the community.  

47The methods include:

1. work on real problems which touch many people in the community and help them to think together about them;

2. do the work progressively with respect to the different problems by making each step sustainable and basing everything on a participatory approach;

3. develop a good partnership among the stakeholders; mainly the state, the local government, the population and the civil society;

4. be aware that there are financial resources in the community despite its poverty. These resources, put together, could raise a mountain;

5. build confidence among the different stakeholders.

48For the future, Bethesda needs to develop a good partnership with a research program in order to better assess the impacts of its integrated approach and communicate them to a wider outside community.