Report on ‘Building Partnerships between communities and their Health systems in Resource-poor Settings’, an auxiliary event at the 35th Global Health Council Conference on Tuesday, May 27, Omni Shoreham Hotel, Washington DC.
Main Discussant and Moderator – Dr Peter Ngatia, Director of Capacity Building, AMREF
Keynote Presentation – Dr Daraus Bukenya, Director of Community Partnering, AMREF
Case Study Presentation – Walter Mukhwana, Aga Khan Health Services, Kenya
Introduction – Dr Ngatia
Health is a human right. Everyone deserves good health, but today it is only a slogan, particularly in Africa and Asia, where people continue to carry a heavy burden of disease, and to die early. Thirty years after the Alma Ata declaration on primary health care, countries like Swaziland and Tanzania have a life expectancy of only 45 years.
We have talked all these years about community involvement, yet as we assess the gains of those 30 years, there is still a gap between communities and health systems. We feel that community partnering will transform communities, from being passive recipients of services to becoming participants in change for better health. If we can actualise community partnering, we feel this will move us to the next level, making communities part of the solution. In that way, we become catalysts of the change, not the change agents.
Keynote presentation – Dr Daraus Bukenya
Community partnering: A missing link in the process of sustainable health development in Sub Saharan Africa.
Purpose of the presentation
- To stimulate discussion on community partnering in African health systems today
- Propose community partnering as a better approach to reaching the Millennium Development Goals in Africa
View the full version of Dr Bukenya’s presentation
View Dr Bukenya's Presentation Outline
Case Study Presentation – Walter Mukhwana
Objectives:
- To explain Aga Khan Health Services’ Community Health Development model
- Look at community involvement in encouraging female education and impact on Ante Natal Care (ANC).
Questions and comments:
- Enumerators, who are they, what are their qualifications, are they paid?
- How can community partnering benefit all sectors in the society which would be excluded if the focus is only on the health sector?
- Why shift from participation to partnering, yet partnership builds on the participation?
Responses:
Walter Mukhwana: Enumerators are community health workers, and members of the communities they live in. The minimum qualification is secondary school education, and they are selected in a participatory process that by the community chief, dispensary staff and AMREF. The enumerators receive no pay, but are given a transport allowance, about 1.5 dollars daily.
Dr Bukenya: We cannot achieve health working through the health sector alone. Unfortunately, the health in Africa has failed to harness multi-sectoral partnership that will impact positively on health. However, a lot is already happening at the district level level, where sectors are working together. This needs to taken up at national level
We are calling for a shift from participation to partnering. A major difference between these two in the way it is being done. The Primary Health Care (PHC) documents asked communities to participate in government or NGO-designed interventions, to comply with what we think is best for them. It is not really a partnership where the community decides what they want. We are proposing that the communities decide what is best for them and invite us to support what it is they want. Communities are a resource; they have a lot of energy and they know what they want, and what they don’t. That is why they abandon what we have provided for them such as ANC clinics because they are not happy with the services provided there, and instead seek their own e.g. traditional care, This has had very serious consequences for example in Tanzania or Kenya, use of maternal care has reduced from 60- 42 per cent. To get the communities to the level where they use the services, they need to be an integral part of the system. Some countries have already taken steps to correct this, although it is still a challenge.
Comment
The issue of low attendance of ANC is complicated: it has cultural overtones, it is related to resource availability, poor infrastructure etc. Therefore as we collect data on use of services we need to keep these things in mind. Thirty-two per cent of women seeking ANC services is low, but we need to know things like at what point these 32 per cent are seeking care. We need to know how many women are protected from malaria in pregnancy. In Tanzania, only 22 per cent of pregnant women use insecticide-treated nets, and so as the enumerators go about collecting data, they need to pass these education messages on.
Breakout sessions
Participants broke off into three discussion groups focusing on three separate questions:
- What needs to be done to overcome potential resistance from governments in the South to uptake community partnering? Who should provide leadership for this, and how?
- What role can institutions and governments in the North play to accelerate community partnering? Who should provide leadership for this, and how?
- What essential additional research and evidence do we need to support this agenda and what else needs to be done by South-based researchers and development practitioners to support this agenda? Who should provide leadership for this, and how?
Group 1
What needs to be done to overcome potential resistance from governments in the South to uptake community partnering? Who should provide leadership for this, and how?
Challenges:
- Trust
- Assumption of problem
- Quality control – who’s responsible
- Limited resources
- Sustainability
- Cultural barriers
- Empowerment
Solutions:
- Pilot programmes
- Involving government and community in decision making
- Increased community participation
- Open communication
- Partnerships with government institutions such Ministry of Health and civil society
Assumptions
- Passivity – trying to get governments involved
- Corruption – government needs to work on this
Quality control
- Responsibility – involving community leaders in decision-making will make them more accountable
- Develop standards of operations
- Community involvement
Limited resources and sustainability
- Empower citizens – through training, internships, job opportunities etc
- Legislative framework for policies on working with community
Cultural barriers
- Communication
- Sensitivity to ethical issues
- Education, to help break through the barriers
Empowerment (authority, power)
- Get community to share responsibility
- Promote democratic values to increase involvement of community in decision making
Leadership would be a partnership between the government, communities and the private sector.
Group 2
What role can institutions and governments in the North play to accelerate community partnering? Who should provide leadership for this, and how?
- Public health agencies should try to understand the communities they serve, identify preventative and health issues in those communities, and strive to understand cultural elements in those communities
- They should ask permission to go into those communities, find out what they need and who should be involved in finding solutions
- Get universities and other learning and research institutions involved
- Government must support more community initiatives. Northern governments must ask more what the South needs
What does the South need most?
Challenge: Funding comes with restrictions from the funder and issues area imposed on the communities
Solution: Participatory action research
Challenge: Often people at the grassroots level suffer because projects are too specific to what funders impose
Solution: Listen to the communities
Challenge: Funders look at numbers and quantity to decide what projects to implement
Solution: Look at quality, rather than quantity
Challenge: Training materials are not user friendly to the South
Solution: We need to involve communities in designing the materials. We should move from a vertical to sector-wide approach
Challenge: No sustainability
Solution: Government Health plans should be developed that are sector-wide, involve community partnership, and are developed by both the community and the government. These requirements should be met before any project receives funding.
Leadership will take a bottoms-up approach, from communities and their leadership structures upwards. Communities need to be mentored so that they can take ownership of the health development process. The North should only be a catalyst for that process.
Group 3
What essential additional research and evidence do we need to support this agenda and what else needs to be done by South-based researchers and development practitioners to support this agenda? Who should provide leadership for this, and how? Research should be done to determine issues like:
- How cost-effective are these partnerships?
- What are community dynamics? How do processes on the ground work at household, community level – social, family, cultural, political etc. How are decisions made?
- Why are people not using health care services – sociological and anthropological studies
- Feedback from CBOs, FBOS etc, what’s working and what’s not working?
- Community empowerment and education on health rights – how do communities define health? Do they realize that they have a right to health?
Leadership would be provided by organizations on the ground, Faith Based Organisations (FBOs), community health workers, community gatekeepers – those people on the ground who control the information but the dynamics within a community. We would need to find out who they are, because they differ from community to community
Conclusion:
Dr Ngatia: Our communities do not participate in health development because they are disenfranchised. They do not understand, they do not have the knowledge to enable them to become part and parcel of the health system. We must also listen to the communities. What are their needs? Simple operational research questions will get us where we want to go. And we must do all this in partnership between the communities, the governments and the private sector.
Dr Bukenya
Challenges
- Commitment of local leadership to community partnering
- Political will to relinquish control and decision making
- Enabling legislative framework still lacking
- Capacity to supervise community initiatives
- Capacity of communities to hold actors accountable
Question:
One of the weaknesses of health systems is that there have been too many policy changes. How do we ensure that we stay on course with this?
Response:
This is not a policy change, it’s a process change. It is just about changing the way we do things. We want to address the failures of community participation which has not worked. So let’s go for community partnering and find ways to make it work.
Question:
As we work at community level, there is an increasing push to recognise traditional healers. But isn’t this pushing people to use untested substances. How do we make sure that we are not exposing people to dangerous practices?
Dr Bukenya:
About the traditional healers and other community systems, this is all about recognising the resource and harnessing that resource, like it has been done with the sangomas of South Africa by AMREF to manage tuberculosis. The most important thing is to see the value that traditional healers and traditional birth attendants add to the system, picking up the positive that we can build on, and what is negative that can be dropped. These people have a role to play, because like in South Africa, 80 per cent of the population will go to traditional healers first. If you don’t want to use the traditional healer as an entry point to health systems strengthening, then you won’t make it. In Kenya we have been able to increase anti-natal care uptake by working with traditional birth attendants, by asking them to refer mothers to the clinics and making sure that all the mothers are delivered and attended to by skilled workers. That way you build trust, and it works!
Conclusion:
Dr Bukenya:
- We are all in for the long haul in our efforts to use community partnering to strengthen health systems.
- We have to prepare communities and governments to take part in the process. Capacity must be built for both, and we need to do a lot of lobbying to get governments to recognise the role of communities and to incorporate them in the health structure.
- We must use a multisectoral approach and bring in other sectors to play a part in improving health.
- We need to adopt a more positive outlook and reduce focus on the negative.
- We must invest a lot in understanding the communities in which we work, even before we incorporate new ideas and technologies. This requires time, and is a challenge because of the time limits set by donors for projects. But it is necessary if we are going to ensure sustainability and to make the money work for the people.
- There is a great need for study in areas which we do not understand, and we also must try and learn and share information so that we can improve the way we work. In September 2007, AMREF hosted a South-South consultative meeting on Connecting Communities with their Health Systems, at which we brought together a number of researchers, policy makers and practitioners from Africa, Asia, Europe and North America, and at the end of it, they agreed that the recommendations could be integrated in the work that they do, and I hope that when we go back home we will be able to find ways to use what we have discussed today to contribute to this agenda.
Dr Ngatia: We should not make community partnering just another buzz word, we should make it happen. Let us go out and catalyse communities to become what they should be, and to become healthier and wealthier.
More resources from the GHC Conference:Press Release: Community Partnering – The Missing Link Press Release: E-learning Solution to Health Worker Shortage Well Received Press Release: Creating common quality standards for improved health care Visit the Global Health Council Conference Website |