Community-Based Development
A Core Driver for AMREF's Strategy 2007-2017
By Dr Daraus Bukenya, Dr Peter Ngatia and Dr Thomas Kibua
1. Introduction
This paper explains the concept of Community-Based Development (CBD) and its application in AMREF in the past, present and future. It demonstrates the link between the AMREF Strategy (2007-2017) and the critical role of communities both as beneficiaries and as primary actors in development. Ultimately, it underscores the notion that communities are at the centre of AMREF’s development approach.
The term community as used in this paper means both ‘community of place’ and ‘community of interest’. A community of place refers to a group of people within a geographical area (village, commune, boma etc), while a community of interest applies to people who have a common need, purpose or function, although it may not necessarily be in the same locality. AMREF views communities as temporal, culturally diverse and mobile groups bound by common needs or interests. They can be groupings such as pastoralists, settlements, schools or factories, or people with particular health needs such as women and children, or people living with HIV or diabetes.
2. Definition of Community-Based Development (CBD)
As a concept and practice, development is viewed as a multifaceted process involving the mobilisation and use of physical, financial and human resources to improve standards of living in all aspects – social, economic, cultural, political and environmental aspects.
Community-Based Development puts grassroots people (communities) at the centre of the development processes. Communities cease to be passive beneficiaries of the desired change and instead become drivers of that change. This transformation is a continuous internal process that builds on the human and social capital that exists in a community, a process that may also be accelerated by outside assistance.
The primary purpose of CBD is to help individuals and communities to gain greater control of their lives by giving them opportunities and resources to develop knowledge, skills and motivation to pursue positive change at personal or community level.
CBD is applicable to development in all sectors. In public health, it is commonly referred to as Community-Based Health Care (CBHC). This is a community-driven and community-based approach to Primary Health Care that empowers individuals and communities to improve their own health and quality of life. It is holistic in that it encompasses preventive, promotive, and curative components of community health. It is supposed to link the community and the formal health care system. Undoubtedly, the main pillar of CBHC is the people’s active participation in the promotion of health, prevention of disease and management of common ailments at community level. The challenge however is that most African communities, particularly marginalised ones, need outside expertise and economic assistance to catalyse such development.
3. Application of CBD
The ultimate goal of Community-Based Development is to improve the quality of life in the community. There are numerous examples in the world where its application has had a positive impact on people’s lives. For instance, the Jamkhed Comprehensive Rural Health Project in India helped impoverished communities to define their development priorities and to nurture the community's own human resources to address these priorities. In this case, child mortality was reduced drastically as a result of the role of community health workers. In India too, the Society for Education, Action and Research in Community Health has recorded massive benefits in overall community health as a result of participatory processes focusing on local initiatives. And in Nigeria, the Rural Health Programme combined community empowerment, rural health and sustainable agriculture, with local people taking the lead in the situation analysis, prioritisation of needs, project planning and implementation, as well as monitoring and evaluation. The outcome after five years indicated improved health and welfare of the communities.
AMREF’s experience in CBD dates as far back as 1964. While discussing health development in Tanzania with the then president Mwalimu Julius Nyerere, Dr Christopher Wood observed that “we (AMREF) want to draw on the strengths of the self help movement in community development so that improvement of health can involve the people and is not just a matter of drugs, doctors and hospitals”. The initiation of the Kibwezi Rural Health Project and the Community Health Worker Support Unit in the 1970s epitomised AMREF’s involvement in comprehensive Community-Based Primary Health Care work and indeed CBD. Community-Based Health Care eventually became the cornerstone of AMREF’s programming. Over the years, AMREF has developed methods that have enabled effective response to emerging challenges and needs through CBHC.
The implementation of CBD in AMREF has been guided by the organisation’s core values and principles, including ‘health as a human right’, ‘pro-poor’, ‘gender equity’ and ‘partnerships’. AMREF believes that communities are resourceful and that empowered communities are a prerequisite for improving individual and community health. AMREF strives to work with and through communities, putting their interests and opinions first.
However, there has generally been weak predesigned community engagement in the past. The selection of communities that AMREF works with has been based on unclear criteria, spanning from donors’ interests to AMREF’s interests, and has even been, to some extent, opportunistic. Entry into communities has sometimes been done with limited baseline information or none at all, and hence without a clear understanding of the people’s priorities. Many times too, AMREF has taken externally-driven initiatives to communities, expecting them to ‘buy in’ and participate. But good lessons have been learnt fromthese experiences and AMREF currently invests heavily in sensitising and mobilising communities to maximise project uptake. The modalities of engagement with communities have evolved over time as shown in the following cases of success:
After the civil strife in Uganda in the 1980s, AMREF moved into Luwero in the northern part of the country to support rehabilitation of the dilapidated health infrastructure. AMREF used the CBHC approach and integrated promotive and preventive health care with curative services. The organisation worked with the Health Unit, community leadership and other sectors. Community systems and resources were mobilised to upgrade the existing referral system for mothers, initially based on ‘human ambulances’, to bicycle ambulances. Other community-based initiatives included a community drug supply system and several income generating activities.
In South Africa, the Sekhukhune HIV/AIDS project used an integrated CBHC approach to address HIV/AIDS and poverty. AMREF played the facilitator’s role, mobilising communities and combining HIV/AIDS prevention and control activities with micro-financing for income generating activities.
Over the years, AMREF has recognised that civil society organisations (CSOs) are effective drivers of CBD. AMREF in Kenya’s MAANISHA programme aims to empower CSOs to design and implement effective community-based HIV/AIDS interventions. Fundamental to the programme’s approach is the view that communities and their CSOs should not be relegated to mere consumers of services, but should be partners in the planning, implementation and review of health system interventions. A mid-term evaluation conducted in 2007 showed that 100% of the funded CSOs were led by elected leaders compared with 20% at baseline; 93% had constitutions or articles of association compared with 68% at baseline; 77.9% of them had clear organisational structures compared with 56% at baseline; 91% were using finances efficiently compared with 22% at baseline; and 72.2% were mobilising local resources compared with 63% at baseline. CSOs were also using grants as planned for home-based care, promotion of safe sexual practices and reduction of stigma.
The Katine Project (2007-2010) in Uganda is referred to as a Community Partnership Project. It is a partnership between the Katine community, the private sector, the district leadership, AMREF and other NGOs including Farm Africa and CARE. From the brief experience so far, there has been increased community awareness of and participation in obtaining basic services, and increased community capacity to plan and budget for their needs.
From these experiences, AMREF has learnt valuable lessons that include:
- Long-term (at least 10 years) programming rather than the short-term approach is essential to CBD. This has financial and other resource considerations.
- Creating community ownership goes beyond participation. Communities must have a stake in the CBD process within a partnering arrangement.
- Community capacity building and strengthening are essential. This implies working with and enhancing the work of existing leadership and other structures and systems.
- Working with governments and other like-minded development actors in a partnership and collaborative approach catalyses better and more sustainable CBD, e.g. Katine. It paves the way for AMREF to work with others with competitive advantages and without competing interests.
AMREF has continuously used these lessons learned to improve on its current modalities of partnering with communities. The health development results of current and future interventions are expected to improve substantially.
4. Alignment with the AMREF Strategy
AMREF’s strategy places the health of communities at the centre of its interventions. Using a community-based approach, AMREF learns how communities view their own health, health care needs and strengths, and how well they link to the formal health sector for services. Together, we design and test models that address specific health issues, such as prevention and treatment of a particular disease, or improved access to a health centre or hospital. AMREF also invests considerable effort in building the capacity of local civil service organisations to decide on health priorities, deliver and manage interventions and work with the rest of the health system.
Building on lessons learned and challenges encountered in implementing CBHC over the last 40 years, AMREF’s approach has increasingly been refocused from working in communities to working with communities. However, while there is evidence that CBHC has succeeded in strengthening community systems, gaps persist in areas such as programme design, monitoring and evaluation, and mutual accountability.
To close these gaps, it is imperative that all AMREF interventions integrate the three themes of Community Partnering, Capacity Building, and Health Policy and Systems Research. This integration will ensure focus on community empowerment and partnering, while the lessons and best practices derived will be aggressively used to influence the practice of CBD in AMREF and in the global arena.
Besides integration, aligning CBD with the AMREF strategy calls the following shifts:
- Starting from what exists within communities: AMREF must stop going into communities with its own set agenda. Instead, AMREF projects and programmes must be ‘community demand-driven’.
- Understanding the communities holistically: AMREF must first study communities and be responsive to what has been learned.
- Working with communities to jointly undertake needs assessment, health systems research and monitoring and evaluation: The use of community resources and social capital will be critically important.
- Adding value to community structures and systems for greater institutional strength and sustainability
- Monitoring and measuring the impact of interventions with the communities
Criteria against which AMREF interventions will be measured for CBD compliance will be established to ensure continuity of learning.
5. Conclusion
CBD is not only relevant to addressing contemporary health problems in Africa, but is also consistent with the aspirations of various African governments to empower communities for the improvement of health and quality of life of their people. There is a shift towards enabling communities to become the drivers of their own development, including health. Through research, monitoring and evaluation AMREF has learnt important lessons about partnering with communities, building capacities and structures, and health systems research to improve CBD, while respecting the dignity, resources, structures and systems of the communities that we work with. AMREF is committed to learning and improving, and to sharing those learnings with others.
AMREF will listen and learn because AMREF truly believes that the answers are with the community.
AMREF's Corporate Strategy 2007-2017 - Putting African Communities First
AMREF is a transparent organisation distributing funds of up to $85 million per year.
