Promoting Community Partnership and Involvement under limited resources: Opportunities/Gains and challenges

URL http://www.the-networktufh.org/conference/previousconferences.asp

By Edwidge Kezaabu Lugemwa

From the VVOB Skills Lab Project -

Kigali Health Institute(KHI) – Rwanda.

AIM: To share ideas of the concept of community partnership and involvement in the promotion

of health in limited resources , opportunities and challenges.

Specific Objectives: By the end of the session participants should be able to:

1. Discuss the rationale of community partnership and involvement in the promotion of

health in limited resources.

2. Share their experiences in community partnership and involvement with evidence

based and best practices.

3. Share ideas related to opportunities and challenges in community partnership and

involvement in the promotion of health.

The process: Presentation, small group discussions, presentations in plenary, general

discussions and conclusion.

CONTENT

Introduction

The key words

What is a community?

The concept of community partnership

Community Empowerment

Community Participation

Community Involvement

Effective Community Communication

Rationale of community partnership in healthy care

Opportunities/Gains

Challenges

Conclusion

Acknowledgement

References


INTRODUCTION:

The vision ‘health people in health communities’ involves broad based preventive efforts and moves beyond what happens in physicians’ offices, clinics and hospitals, beyond the traditional medical care system to the neighborhoods, schools, workplaces and families in which people live their daily lives. These are the areas where a large proportion of prevention and rehabilitation occurs. Considering the emerging public health concerns, objectives that accurately reflect data can be developed, revised and re revised. The set objectives to address health concerns should be used with potential data source and when revised they should reflect the most current science. Achievement of such objectives towards health promotion in low resource environments can be attained fully with increased Community Partnership and involvement towards best practices.

KEY WORDS

Health, Health promotion, Evidence based and Best practices, Community Partnership.


* Health, defined as the state of complete physical, mental and social well being and not merely the absence of disease or infirmity,(’WHO)’ is also described as ‘a process of continuous adjustment to the changing demands of living and of the changing meanings we give to life’. It is further described by medical scientists as a level of functional and/or metabolic efficiency of an organism at both the micro (cellular) and macro (social) level to restore and sustain a ‘state of balance’ known as homeostasis.



Health Promotion, according to the Ottawa charter of health promotion,1996, is a set of activities designed to achieve optimal health for all by maintaining and enhancing the health of everyone and facilitating individual and communities to increase control over factors that influence their health /determinants of health, and thereby improve their own health’

‘’Best practice in health promotion’are those sets of processes and activities that are

consistent with health promotion values/goals/ethics/beliefs, evidence, and understanding of the environment and which are most likely to achieve health promotion goals in a given situation, (Best practice in health promotion, Kahan & Goodstadt,IDM Manual,April 2002’’).

Evidence Based Practice is an approach to care where health professionals use the most current and appropriate information available to make decisions related to clients’/patients’ care.

EBP therefore promotes the collection, interpretation and integration of valid, important and applicable client/patient – reported, provider – observed and research derived evidence, Mitchell, G.J.(1999).

WHAT IS A COMMUNITY?

Ferdinand Tonnies in 1887 argued over the word community (Gemeinschaft) differitiating it from society (Gesellschaft). Community is perceived to be a tighter and more cohesive social entity within the context of the larger society due to the presence of a ‘unity of will’ or sense of the community one is identified with.

A Community is defined as a social group of organisms sharing an environment, and normally with shared interests. In the human communities, intent, belief, resources, preferences, needs, risks, common leadership and a number of other conditions may be present and common affecting the identity of the participants or the particular members of a community and their degree of cohesiveness. Membership, Influence, Integration, fulfillment of needs and shared emotional connection are elements of a community identified by Mcmillan and Chavis in a study they carried out in 1986.

THE CONCEPT OF COMMUNITY PARTNERSHIP IN HEALTH CARE

A partner has been defined by the oxford English Dictionary as a sharer. This implies that, the health care practitioners should be able to share knowledge, expertise, skills, beliefs, values and decision making with the clients in a one to one basis, with family or community as groups and to accept what they offer in these areas as both valid and respected, even when it differs fundamentally from their views. As a partner, the practioner should refrain from making judgments about the individuals, families or communities but should be able to share perspectives on an equal footing, and with their participation where possible, Ashworth et al. (1992).

It is important to note here that participation with others presupposes that each person is receptive to others’ contributions, and that each is able to assume the receptiveness of the others. But partnership goes beyond participation although both participation and empowerment are sometimes equated to partnership.

In partnership for health care, the aim is to promote health with the people, and not just to provide medical care for the people. In this case, partnership acts as a multiplier whereby individuals or members of the community become the agents of change, taking new health patterns and new ideas to other individuals, families and communities. Community partnership at first may seem to be a slow process but later this multiplier effect causes a rapid increase in growth, promoting health even in very low resources environments. The community members, with a great store of knowledge and skills reinforced with further training where possible can provide more and yet appropriate primary health care because they understand their local health concerns and needs more than anyone else outside their social interaction circles within their communities.

COMMUNITY EMPOWERMENT

Partnership is only in words without empowerment. Empowerment is a social process of recognizing, promoting and enhancing people’s abilities to meet their own needs, solve their own problems and mobilize the necessary resources in order to feel in control of their own lives, Gibson (1999). Community empowerment therefore occurs by empowering individuals first so as to make up empowered communities. Formal and informal education, the former being promoted through the bottom - up approach and community involvement are some of the strategies to empower individuals and communities. Through partnership, individuals and communities can be empowered but lack of empowerment means that people perceive themselves as powerless and not in control of their own lives or conditions which determine their health and

Empowerment is a multidimensional, social process, It occurs at various levels that is; at individual level, group or community level. It is a social process that fosters power ( that is, the capacity to implement) in people, for use in their own lives, their communities and in their societies, by acting on issues that they define are important, Bailey (1992). But it is not possible to offer people power so as to make them empowered, the focus is on the connection between individual actions to community action, encouraging individual change by supporting participants’ efforts towards community change.

COMMUNITY PARTICIPATION

Involvement of the people to solve their own problems is termed as participation although people cannot be forced to participate there should be all possible opportunities for them to participate in matters related to their health. Participation is held to be a basic human right and a fundamental principle to democracy (Goyet, 1999).

According to Goyet, participation does not occur automatically, it is initiated and goes through a process. In his guide towards participation, it is seen that it goes through four stages; initiation, preparation, participation and continuation. Participation can take place during any of the following activities; needs assessment, Planning, Mobilizing, Training, Implementing, monitoring and evaluation.

Understanding participation involves understanding power as well (the ability of different interests to achieve what they want). Power depends on who has the information, confidence and skills among other things. The reason why most community initiative programmes do not allow full participation of the local people is the fear that they will lose control of the assumed power. In participation there are incentives and disincentives and effective participation is most likely when the different interests involved are satisfied with the level at which they are involved.

Levels of participation

This guide supported by the Joseph Row tree Foundation and written by David Wilcox proposes a five-rung ladder of participation which relates to the stance an organization promoting participation may take.

Information: merely telling people what is planned.
Consultation: offering some options, listening to feedback, but not allowing new ideas.
Deciding together: encouraging additional options and ideas, and providing opportunities for joint decision-making.
Acting together: not only do different interests decide together on what is best, they form a partnership to carry it out.
Supporting independent community interests: local groups or organisations are offered funds, advice or other support to develop their own agendas within guidelines.







COMMUNITY INVOLVEMENT

Community involvement goes beyond community members checking whether they are happy with the services being provided. It is a more radical approach which sees community members involved in decision making during community programme design and management. This approach requires many people to completely change the way they approach their work.

The different ways of community involvement can be classified according to how much power is given to community members. The table below may help you decide at which level you would like to involve community members, and note here that in community partnership and involvement all parties are involved.


Self help
Community members take the initiative to take action on their own. If they get assistance from authorities it will only be for advice or resources, which they will control.

Partnership
Community members and outside experts plan design and take decisions together.

Consultation
Committee members are consulted by the outside authorities who listen to their views. The outside experts then decide what the problem is and how it should be solved. All decisions are made by the outsiders.

Information giving
Local people participate only by being told what is going to happen or has already happened. It is an announcement by e.g the project management without listening to people’s responses.

Adopted from Arnstein (1999)


EFFECTIVE COMMUNITY COMMUNICATION

Effective Community Communication is key to successful Community Partnership. Open, positive and respectful communication helps build commitment and trust in a community, leading to increased interest, support and involvement in community life. It is usually very difficult for community members to get involved when they do not know what’s going on. Whether it is at the community level or one to one, communication is most effective when it is two way; At the community level, this involves giving information and asking for feedback. Once information is exchanged, citizen involvement in local activities will increase and resources will be developed. A clearly established communication network is key to successful partnership.

RATIONALE OF COMMUNITY PARTNERSHIP IN HEALTH CARE

o The partial success of some models of health care to offer the basic health services to the poor.
o In Successful scaling up of the interventions related to health needs identifying ways in which services can be added to the already existing services
o Shifting successfully to community based and patient centered (Individual) – paradigms of care for the proper management of chronic diseases that include HIV/AIDS and cancer has given way to interventions that necessitate community partnership.
o To preserve health in conflict and post conflict areas so as promote health of the marginalized, the hard to reach and to address the unmet needs.
o To promote health of the vulnerable eg the children, the women, people with disabilities (PWDs), the elderly, the adolescents, and the incarcerated.
o Other special groups of people like the prostitutes, substance and drug abusers, the sexually abused, the mentally ill and those with other risky behaviors / behavioral disorders
o Deploying towards a continuum of care - One of the core competencies for long term care is partnering. .
o Provision of community mental health services relies heavily on effective educational outreach programmes .
o Studies show that there is an ever inceasing decline in the total resources towards the health sector in most of the low developed countries that include the human resource for health care services (C.H Wood et al,2001).
o Shortage of health workers as a constraint to achieving the three health related MDGs , that is , reducing childhood illnesses, improving maternal health and combating HIV/AIDS and other diseases such as Tuberculosis and Malaria.
o Simplification and delegation of tasks to less skilled colleagues, this was done in the global polio eradication initiaves and is still being well implemented in promoting oral rehydration therapy and home based management of malaria.( The World Health Report,2006)
o The gap between the haves and the have nots is becoming wider within countries where leadership is lacking at certain levels to support the rights of the underprivileged and if at all it is supported it is not with similar strength as compared to the support given to the beneficiaries of privatization.
o The problem is not the know how because lists of human resource for health are being released and the number of graduates in the medical fields would be just enough, the problem is the number of patients accessing services is increasing as compared to the resources to meet their needs.
o Health care eventually returns to the community with reference to clinics or hospitals when necessary.
o Although there has been increasing technology and new drugs , the concern is on the extent to which health services provide coverage to the communities they serve. Still the poor are not reached and even when health services are accessed individuals, families and communities should are seen as just consumers but not active partners in all matters related to their health needs and concerns.
o Questionnaire surveys, action research, extractive research are being superseded by investigation and analysis by local people themselves. Methods and approaches to research are not only used for the local people to inform outsiders, but also for peoples own analysis of their own health needs, conditions, and concerns (Chambers, R. ,PRA Methods and Tools,1992).
o The determinants of health, eg poverty ,gender inequality, social capital, income inequalities, cultural values, employment/working conditions etc, have been seen as having great influence to the well being of individuals, families and communities. Recent findings and analysis of emerging issues brings to light of the concern that goes beyond mere biomedical and behavioural risks ( The Ottawa charter for health promotion,1996)
o As health progresses from traditional to scientific, it must combine the best features from both in a radical community based model.
o The emerging public health concerns and that infectious diseases are spreading faster geographically ( WHO report,2007) , making all populations vulnerable.
o At Local level, communities have responded to disasters faster before government interventions.
o PLWHAs have proved to be a valuable educational resource to support the training of health workers.
o Adressing diversity and socio – cultural and demographic characteristics of populations.



OPPORTUNITIES/GAINS

* Since the Alma Ata Conference of 1978, a primary health system with full involvement of the people has been seen as the key to bringing about health for all..
* Current and realized transformation are that partnership is increasingly mandated and employed as a vehicle for health education , promotion of health and prevention of diseases, this was shown in programmes such as that for safe motherhood, Integrated management of early childhood illnesess, and Roll back malaria
* The Millennium development goals (MDG) agreed at the United Nations Millenium Summit in September 2000 where nearly 190 countries have subsequently signed upon them.The MDGs are the wold’s time bound and quantified targets for addressing extreme poverty(the number one cause of poor health) in its many dimensions. They are to address human rights – the rights of each person on the planet to health,education,shelter, and security. The road map towards the implementation of the MDGs realized the progress made in the prevention and treatment of diseases ( UN Secretary General report,2002).
* The roles demonstrated by the health sector as Leaders, Influencers, communicators and knowledge brokers.
* Collaboration towards multisectoral approaches of addressing issues, that is ,putting in place desks to address health related concerns and the decentralization process.
* Some communities have experienced a fast growing and sustainable partnership because of collaboration and flexibility in governance and leadership as the most recognized strength in community partnership.
* Practice – based teaching and problem – based learning : Institutions benefit from collaboration with community partners by developing research initiatives in the area of Public health practice and enhancing their practice based curriculum with practice to prepare students and Communities and agencies benefit from specific projects and research initiatives that promote public health.
* Patient focused interventions which recognizes the role of patients as active participants in the process of effective, safe and responsive health care. As individuals or family members patients can play a distinct role in their own care by diagnosing and treating conditions, by preventing occurrence or reoccurrence of diseases or harm , by selecting the most appropriate follow ups with the health professionals for more serious illness, and by actively managing long term conditions. Recognizing such interventions that strengthen them is seen as fundamental to securing a more patient – centered approach to health care delivery.
* Community partnership has actively managed the HIV/AIDS Care and Anti retro viral therapy in treatment support, keeping the drug regimen (adherence) through simple monitoring.
* Volunteers at village levels have proved to be an untrapped and yet potentially valuable resource. When identified and trained, volunteers have succeeded in certain communities to identify, refer and follow up people in their villages.
* An approach to community Based Participatory Research actively involves the community studied in the research through partnership.
* The presence of community Based Organisations such as churches and church members, community residents and other social organizations.
* Concepts, theories and models have shown evidence that partnership is still the only possible way to promote health with best practice, eg the Interactive domain model by Kahan & Goodstadt , April, 2002.



CHALLENGES

* A lack of political leaders to remove bureaucratic controls and free communities to take more responsibility for their own health. Much has been done in the name of decentralization and district focus but there is little real empowerment of communities to enable them to identify their health needs, choose priorities, design and implement interventions and monitor and evaluate the impact of those choosen interventions with the central government doing supervision and possible funding.
* The current policies that are developed only focus highly on Institutions based clinical service which has brought about severe cutbacks on the promotive, preventive and outreach services.
* The success will also depend largely on communities demonstrating worldwide that they can bring about effective and sustainable improvements in a cost effective manner.
* Corruption and its consequences.
* Progress towards the achievement of the MDGs is far from uniform across the goals with sub sahara Africa being in the epicenter of the crisis with continuing food insecurity, a rise of extreme poverty, stunningly high child and maternal mortality, a large number of people living in the slums and a widespread shortfall for most of the MDGs.
* Despite clear evidence that the social determinants of health affect health and illness, the health sector is still reluctant to champion policies that improve social conditions because areas of social and economic policy largely fall outside of the health department’s jurisdiction (Browne G. Nov;2002)
* Despite the increasing popularity and potential, there exists limited evidence of the effectiveness of partnership in achieving the desired outcomes. The measurements and indicators of public health changes as a result of partnership work , the quality of partnership processes and outcomes are failing to be measured effectively. The critical limitations of the existing research that constrain the way we think about and build evidence base for partnership work.
* While measuring functioning and the impact of partnership work over time is ideal, longitudinal designs are not always practical in community settings given limitations in time, funds and rewards of academics for collaborating in community work.
* Qualitative work related to the effects of partnership is not well published in journals, and although it is , findings of multiple studies are not well synthesized that the data and methodology are accessible to practioners and policy makers (Grammer , Sharpe, El Ansari et al.)
* Globalization that fosters the moving of people (labor) across borders and therefore the resurfacing of infectious diseases.
* Targets cannot be met if the resource estimates are not met,( Benjamin Johns et al in resource estimates for global maternal and newborn health services).
* Lack of incentives for communities to get involved in partnership, eg training, skill building and development, funding etc
* The need to increase incentives for universities and research organizations to conduct Community Based Participatory Research, carry out needs assessment to seek partnership
* Lack of trust by the communities highly embedded in social cultural ties.
* The bureaucratic power held by providers as owners of the knowledge related to health although they do not own those whose health needs is addressed to.

CONCLUSION

Partnership will not just happen if we arrange just a few meetings and keep hoping for the best. The ability to bring about participation has to be learnt and practiced; At the beginning many of the poorest and most exploited communities may not grasp the idea at all, nor show any interest. By making our aims clear, have community attachment through listening and respect for community members, and making the people realize that we are not merely providers, then their participation will be genuine. Avoiding professional biases that misguide real practice and aiming to bridge between academic work and practice.

Acknowledgement

VVOB / KHI Project - Rwanda

Kigali Health Institute – Rwanda

The Embassy of the Republic of Uganda in Rwanda.

TUFH Conference Secretariat 2007, Kampala – Uganda Conference.

Makerere University conference organizers.

Bank of Africa – Uganda.

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