Collaborating with communities: the Empowerment Paradigm

 Vijayaprasad Gopichandran

Assistant Professor, Community Medicine, ESIC Medical College and Hospital, KK Nagar, Chennai 600078 email: vijay.gopichandran@gmail.com

 

Lecture prepared to be delivered on 31 May 2023 at the Indian Institute of Health Management Research, Jaipur, as part of the course on “Building collaborations across sectors” to students of MPH (Implementation Science) 

 

I have been asked to speak to a group of professionals who are currently studying implementation research in public health on the theme of building multi sectoral collaborations in public health. I think the greatest form of collaboration in public health is collaboration with the community. Community is the most important stakeholder in the public health enterprise and therefore collaborating with the community is an essential component of successful delivery of public health services. What follows are my lecture notes. I intend to talk to these specialists on empowerment as an important social construct in communities, the moral and ethical underpinnings of empowerment of communities, the elements of community empowerment opportunities in public health, the concept of partnerships and collaboration and some of my experiences of collaborating with communities to achieve public health goals. 

 

What is empowerment?

Empowerment is the process by which people gain control over various factors and determinants of that influence their life. As the word suggests it ‘gives power’ in the hands of the people to control their own lives. Empowerment is a great social goal that all communities strive to achieve. Empowerment can be movement of the people from a position of vulnerability into a position of security, or it can be upward social movement from a point of security to point of realization of full potential. 

 

Several social factors such as gender, class, education, occupation, religion, caste, culture, race, ethnicity etc. have power over people’s lives. They influence people’s lives in many ways including their health. 

·      Social empowerment is change in the power differentials inherent in the society due to these factors. For example, women’s empowerment is removal of all kinds of discrimination against women; caste empowerment is removal of untouchability, affirmative actions and provisions for improvement of the lives of people belonging to oppressed castes.

·      Economic empowerment is improvement in the livelihood, capacity to purchase goods and enjoy services that are offered. Economic empowerment ranges from interventions to alleviate poverty, to industrialization, and employment for betterment of the lives of people. 

·      Political empowerment is awareness, power and access to influence changes in the political system. In democratic societies, elections are a great way of political empowerment of people. A well informed voter will be able to influence the political climate of the country in a positive way and that is political empowerment. 

Empowerment is transformative in nature and brings about a positive change in the society. It fosters a sense of self-determinantion in the community, where community becomes powerful to influence its social, economic and political structures. It is an ethical imperative for public health interventions to try to empower communities. Several ethical principles underpin this mandate. 

Ethical principles underpinning community empowerment.

Public health interventions and the public health system have an ethical obligation to empower the communities that they serve. Firstly, empowerment is a common good. Common good refers to the condition that is equally beneficial to all member of the community. Empowerment of the community in terms of social, economic, political and health aspects is a common good, because it is common to all members of the society. However, the usual challenges of common goods are also inherent in the empowerment paradigm. Communities are inherently diverse and therefore what is good to one may not necessarily be good to another. For example, gender empowerment through reservation of jobs for women, may adversely affect the employability of some men. Though everyone may agree upon the fact that women must be empowered, which jobs must have positions reserved for women, could be a matter of contention. Empowerment fosters a sense of self-determination and autonomy in the community. When the power to determine their health is given in their own hands, community considers all pros and cons before acting. This way harms are minimized. Communities have insights into unanticipated benefits and risks of public health interventions, and this will greatly enhance the value of the public health intervention. Empowerment ensure justice and fairness by removing inequities in access to health care and services. An empowered community has a sense of solidarity and standing up together for a common cause. These ethical principles underpin the paradigm of empowerment of communities through health action. Public health provides various opportunities to community empowerment. 

 

Community empowerment through public health

CEA Winslow’s popular definition of public health states: “Public health is the science and art of preventing disease, prolonging life, and promoting health through the organized efforts and informed choices of society, organizations, public and private communities, and individuals.” Inherent in this definition are the various dimensions of empowerment of communities. It is an organized effort of the society, with collective action and multi-sectoral collaborations. People take care of their own health, and in the effort, they are empowered. The public health enterprise gives rise to several opportunities for empowerment. Some of these opportunities are:

·      Collective action of society towards healthful living – e.g., an urban community deciding to set up walking and cycling tracks to promote physical activity. 

·      Encouraging and promoting programs initiated by the community – e.g., a rural community adopting a local Anganwadi center and providing nutritious food supplements and play materials for the children 

·      Building community skills and capacities – e.g., a local NGO in a village training local volunteers to do door to door recording of blood pressure and blood sugar for screening for hypertension and diabetes.

·      Improving livelihoods of local communities – e.g., a local NGO organizing a cooperative farming society to market products of organic farming by local farmers thus improving livelihoods and quality of life

·      Providing resources and capacity building of communities for advocacy – e.g., a local NGO working with TB survivors identifies champions who have survived TB and promotes awareness messages to communities through them, this empowers the TB survivors as champions. 

These are just a few examples of empowerment through public health interventions. There are many more such opportunities. Next, we must understand what collaboration is and how collaboration with communities empowers them. 

 

What is collaboration with communities?

Collaboration is where two or more independent parties come together, work together towards a common goal. Collaboration with communities implies that the public health system comes together with the local community and works together to achieve the common goal of good health for all. Collaboration with communities ensures representation of all sections of the community in the public health action and decision making. When the public health system collaborates with the local community, they bring complementary strengths to the table. The public health system brings knowledge, skills, and expertise, whereas the community brings experiential wisdom, preferences and needs. Collaboration with the community also ensures that there is de-duplication. 

 

The spectrum of partnerships between various stakeholders towards achieving public health goals ranges from networking, coordination, cooperation to collaboration. Networking is the mere exchange of information between the parties. Coordination refers to exchange of information and modification of behaviors. Cooperation is exchange of information, modification of behaviors and sharing resources to achieve common goals. The highest form of partnership is collaboration where in addition to exchange of information, modification of behaviors and sharing of resources there is also empowerment or capacity building. Therefore, in the spectrum of partnerships, collaboration is the truly empowering option. Collaboration is empowering in nature. Collaboration with the community is not just a means to empowerment, but it is empowerment in itself. 

 

Working with communities has had several names and each of them is a different level of partnership with the community towards achieving public health goals. 

·      Community consultation is a respectful work with the community, where the community is considered an expert who brings insights regarding what works best for them, how it works, and how it must be delivered to them. The community enters the intervention at an advanced stage of design, after all the plans are made to obtain their inputs. The insights of the community obtained through consultation is used to modify the intervention appropriately. 

·      Community participation is more involved than community consultation. It stands for the process by which communities actively involves in decision making regarding public health interventions, mobilize resources for it, and implements it in the ground. Community participation is one of the four founding principles of primary health care. 

·      Community engagement goes one step ahead and involves communities in public health priority setting, choosing the appropriate public health interventions based on their needs and priorities, and takes a front seat in driving the planning, implementation, monitoring and evaluation of the public health intervention. It is a typical bottom-up approach to public health practice. 

Community collaboration is close to the idea of community engagement, where in addition to the community driving the intervention, it is empowered to take care of its own health. Thus, collaborating with communities belongs in the empowerment paradigm. In the following section, I will share some of my experiences of community collaborations and how they led to empowerment of the local communities. 

 

RUWSEC model of Community based peer support intervention for diabetes

Rural Women’s Social Education Centre (RUWSEC) is a community-based NGO working in Chengalpet district for more than 40 years. It was started as a community-based NGO by a group of 13 dalit women to work in the rural villages in Chengalpet area in the Tirukazhukundram and Tiruporur blocks basically to increase awareness about women’s health, sexual and reproductive health, and rights. Slowly and organically the NGO expanded its services into building a community based rural secondary care hospital, where basic maternal and child health services including delivery, immunization and contraception was delivered to the local rural communities. The NGO has also worked closely with adolescent girls towards adolescent life skills education and in prevention of domestic violence in communities. The NGO has now further diversified its activities to include non-communicable disease services including diabetes, hypertension, heart diseases at a primary care level. RUWSEC, being a community-based NGO, has always worked on the collaborative model of empowerment of the community. The components of collaboration with community

1.     The NGO was founded by 13 women belonging to dalit community in the local area, to work for welfare of dalit women in the area. 

2.     Based on the felt need for a clinical service, the women started their own secondary care hospital, purchased land at a nominal cost from the local community, built the hospital with available local resources including human resource. 

3.     Most of the hospital staff including the nurses, housekeeping staff, counselors, pharmacist, laboratory technicians are people from the local community. They work there with a sense of solidarity. The salaries are much lesser compared to market rates, but still they work there for the sense of fulfilment that they get and convenience of the hospital being close to their homes. 

4.     People have a sense of ownership of the hospital and the outreach services, and actively engage and participate in it. 

5.     Local companies, banks, shops sponsor events and programs in the NGO as they identify it as a unit working for their people. 

Thus, all components of collaboration, namely information exchange, changes in health behavior, sharing of resources and empowerment have happened in the local community due to RUWSEC’s community collaboration. 

 

RUWSEC started a community-based peer support intervention for persons with diabetes in the local area. The intervention was initiated in the year 2010. Initially it was initiated as a hospital-based intervention. Patients with diabetes who visited the clinic were brought together as a support group and they were provided health education on various aspects of diabetes self-management. But this was not a need-based and empowering intervention and could not be sustained much. After experiencing the support group meetings, some of the community members decided to organize such support groups in their respective villages. They formed themselves into support groups and invited the community health volunteers, also women from the local community, to facilitate these support group meetings. At this point, the support group intervention became truly collaborative. 

 

 Community based diabetes peer support meeting with RUWSEC volunteer facilitating the session

RUWSEC collaborated with local communities where the local communities organized themselves into diabetes peer support groups and invited the volunteers to facilitate the sessions. They arranged a space in the villages, either temples, or schools or Anganwadi centers where such meetings would take place. They organized tea and refreshments that was prepared in the home of one of the community members. They invited the community health volunteers to facilitate these meetings and even participated in setting the agenda for the meetings. After it became a collaborative model, the support group intervention has been continuously functioning till date. 

 

A community based diabetes peer support meeting in progress

 

There is a need to evaluate the impact of this peer support intervention at the community level. There is a need to see if empowerment has happened because of this collaboration. Anecdotally, I have observed that the women and men who are part of the peer support intervention have greater awareness of lifestyle modifications and generally have better diabetes control. One empowerment that has happened is creation of an overall level of awareness about diabetes, its treatment, control and complications in the local community. It is possible that this awareness generation is a manifestation of empowerment that has happened due to the peer support collaboration. 

Health facility based diabetes counseling support provided by RUWSEC counsellor 

 

 

In summary, empowerment is an ethical obligation. Every community must be empowered in its pathway to development. Empowerment is embedded in the process of collaboration with communities towards achieving public health goals. The RUWSEC model of collaboration with communities for the diabetes peer support intervention, helps us understand the role of collaboration in empowering communities.