In bringing about behavior change in public health, we often focus on the individual mother, student, or farmer. We should not forget the community structure and norms constrain for encouraging individual health behaviors. This course examines the community context of the changes needed to promote the public’s health. We begin by examining the various definitions of ‘community’ and the processes by which we ‘diagnose’ or seek to understand the structure and characteristics of different types of communities. An appreciation of community similarities and differences is necessary lest we fall into the trap of designing one-size-fits-all interventions. We need to recognize that no matter that outsiders may view a community as poor or neglected, we can find strengths and capacities for improvement in each community. Identifying community capacities and resources is the first step in facilitating community change. Different practical and philosophical approaches to change and therefore, examined. Specific to the change process is our recognition of the need for communities to participate in the design, implementation and evaluation of any intervention. We examine the concept of participation in an effort to see how different levels of involvement may affect sustainability of community change efforts. Finally a case study of a community participatory approach to onchocerciasis control in Africa is presented. Community Directed Intervention has subsequently been successfully applied to providing other essential primary health care services by and in the community, such as insecticide treated bednets, malaria treatment, vitamin A distribution, deworming medicines, and pneumonia and diarrhea case management.
Lecture 7: Community Coalitions
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来自 Johns Hopkins University 的课程
Community Change in Public Health
72 个评分
从本节课中
Module 4
This week, we'll look at community coalitions, contrasting community-based and community-directed programs, and the results of enhancing community-directed treatment.
与讲师见面
William Brieger, DrPHProfessor, Health Systems Program of the Department of International Health
Bloomberg School of Public Health
[MUSIC]
We talked in the previous lecture about the political economy.
How that implies a need to redress imbalances in power relationships.
And one way in which communities organize themselves to address such problems, can
be through the formation of community coalitions.
In this lecture, we will define coalitions and we will look at some
examples. In particular, we will consider a program
in Lagos, Nigeria, one of the largest cities in West Africa and see how a
program sponsored by the US Agency for International Development brought
together groups such as trade associations, religious groups,
neighborhood improvement societies, social clubs.
Together with private health service providers, to form coalitions called
Community Partnerships for Health, CPH. And these CPHs address the issues of
access to healthcare for children in particular.
The urban setting provided a challenge in terms of the political economy model.
Because many of the communities are poor. Even though they are in an urban center,
people have lack to access of healthcare because of costs.
Government clinics are not available everywhere, private clinics are
expensive. People use medicine shops.
The environmental conditions in a community foster the spread of diseases,
diarrheal diseases. The close proximity of population means
that diseases that could be prevented by immunization such as measles spread
quickly. And in order to address these problems,
coalition is formed, partnerships were established.
This will be explained after we've had some comment on the definitions and
characteristics of coalitions. Coalition is an organization of
individuals representing diversed organizations, factions, constituencies,
who agree to work together to achieve a common goal.
A variety of organizations could include citizen groups, professional groups.
These diverse groups, interest groups, combine their human material resources to
affect specific change which members are unable to bring about individually or
independently. This issue of focusing on a particular
goal is important. Organizations, as we will look at in the
next module, have their own individual goals and purposes that have arisen out
of their environments. But individual organizations may not have
the resources to solve all their problems.
There may be organizations with similar, although not exactly the same goals, or
who may focus on different aspects of a health issue. And if they worked
together, they could be more effective as a group.
A coalition may focus on developing the local community, each contributing, each
organizational member contributing what it can provide in terms of skills,
personnel. Coalitions can also be using community
action, to lobby, to pressure agencies and governments to provide more
resources. Coalitions allow individual organizations
to become involved in broader issues without them having to take the sole
responsibility for managing and developing these issues.
And coalitions demonstrate and develop widespread public support for issues,
actions, and unmet needs. Coalitions maximize the power of
individuals and groups through joint action.
They increase the critical mass behind a community effort, to bring about specific
objectives that may be beyond the scope of any one individual organization.
And coalitions also help to minimize duplication of effort.
As noted, several organizations may have a similar goal and by working together,
they can use their resources more effectively, they can improve
communication about particular health issues in a community, and increase trust
among the partners that collaborate. Coalitions help mobilize more talent,
resources, and new ideas and approaches to influence an issue, more so than any
single organization could have achieved on its own.
Coalitions provide an avenue for recruiting diverse constituencies.
They may be groups that have a political agenda, may involve the business
community, professionals in the human services, social and religious groups, as
well as prominent individuals can come together when they perceive a common
need. Coming together as a group, they're able
to exploit new resources and change situations because, again, coalitions are
flexible. They are formed for a particular issue.
They are able to respond. They're not bogged down in various rules
and regulations that the contributing organizations may have had.
They are more responsive to problems in the environment.
There are different kinds of coalitions, grassroots, coalitions are organized by
volunteers, at the community level in times of crisis or to pressure political
policymakers to act professional coalitions, bring together, professional
organizations, medical, nursing, social work, to combine their power and
influence where needed. Community-based coalitions bring together
both professional, and grassroots leaders to work together on the long-term welfare
of the community Successful coalitions result in an exchange of resources and
ideas among the member organizations. It sets up a new level of cooperation
within the community and people will see greater benefits for joining in the
individual organizations that are members because they have a broader influence on
activities in the community. Successful coalitions focus on a clear,
clearly articulated mutual need or concern.
A coalition that focuses on teenage health.
A coalition that focuses on drunk driving.
A coalition that focuses on improving education will be more successful than
those that are interested in just general community development.
Successful coalitions occur in communities where there's a history of
previous collaboration and joint efforts. Success occurs when there is
compatibility among the potential members, when they're not conflicting for
membership or fighting over the agenda. Coalitions are successful when the
members have determination to work together.
Because coalitions are groups of organizations,
each organization in the past has had its own agenda, its own identity.
They may have been in competition for memberships or resources before.
So, a coalition to succeed needs to foster a good climate of good
relationships among the members seeing that there is more to be gained by
cooperating than by competing. Coalition needs access to external
support and resources. Here again, is the value of joining
together. Some members may have contact with the
media. Some member organizations may have
political influence. Some member organizations may have
financial resources. Different organizations may, because of
the nature of being a membership group, may have contact with a national level
organization, they may be chapters. And so, these kinds of external support
and resources help the coalition gain information, gain additional resources to
solve it, the problems. Coalitions, like any organization in a
community, need to actually have achievements in order to stay together.
An organization or a coalition that works for several months or years without
seeing any results are likely to disband. Short-term successes are important to
increase motivation and pride and enhance credibility of the organization.
It's important therefore that coalition members set achievable or reasonable
goals and observable indicators of progress along the way to keep members
interested. The idea of coalition building was
carried out by the basics program, a USAID project that in other countries,
was involved in strengthening the health services.
Ironically, when they reached Lagos, it was the time of political change,
military dictatorships and US government agencies were not allowed to work with
Nigerian government agencies. And so, the project have to look for
another way to strengthen and improve the child survival programming at the
community level. They came upon the idea of establishing
community partners for health in six of the poorer communities or neighborhoods
in Lagos. The concept was based around a
collaboration between private health providers who are ubiquitous in the, in
the community and existing community groups.
Initially, an inventory of community groups and private providers was
conducted. And these two sets of organizations were
invited to a forum to discuss their mutual interests.
Groups such as hairdressers association, tailors association, men's and women's
clubs and groups from churches and mosques, social clubs, came together with
the proprietors and staff of private clinics in the community, and discussed
how they could work together to improve the health of children in their area.
Although several hundred organizations were identified,
community-based organizations, civic organizations, and professionals in
terms of the private providers. In the end, approximately 200 member
organizations formed into six different coalitions or community partnership
groups in the six different communities. As noted, a coalition needs rules so that
each member organization knows its responsibility.
And relationship to each other. And one of the first activities for each
of the six community partner groups was to develop their own memorandum of
understanding. One of the key issues that was of concern
in terms of child health in the urban setting, was access to affordable care in
a timely manner. People knew that private clinics were
available. People knew, of course, the government
clinics were available but they very rarely had drugs or supplies.
So, they knew that private clinics were available.
They were much more costly. There was an agreement made that the
private clinics who were members of the partnership would provide reduced price
healthcare, and would provide this on credit if the member community-based
organization, CBOs, also agreed, or guaranteed that they would cover the cost
of any member who defaulted from payment. This was one of the core understandings
that the, the groups came together with. They also agreed mutually ro promote
childhood immunization, to pro, promote clean environment in their area.
They agreed on such things as membership dues, they agreed on developing a, a
Board of Directors. But this issue of coming up with their
own rules made it possible for them to work together and to know where each
member stood. They were able, therefore, to set out
clear goals. So, we mentioned some of the groups were
more successful than others. The two groups that had the higher
collective efficacy score were able to set up environmental sanitation
exercises, AIDS awareness campaigns. They set up a saving cooperative for
their members. So, they were able to achieve some
organizational successes and engage in fundraising.
They were also able to use their status as a recognized group to get registered
with the government as a non-governmental organization.
And then, the issue of external support, they took this registration paper to some
of the donor agencies, such as UNICEF, and were able to use that to get supplies
of oral rehydration salts when a cholera epidemic broke out, able to get
recognition from, from other agencies for programs.
And so, this partnership was even able to convince the local government.
So, the AID couldn't go directly to the local government but the partnership
could and convince the local government to provide them with vaccines,
so that they participated actively in the immunization program and were able to
increase immunization coverage in their communities.
The CPHs, the Community Partnerships for Health, were able to sustain themselves.
They've been going now for four years, because they built on existing social
units. They identified CBOs that were concerned
about healthcare and welfare of children, and this was the basis for successful
coalitions, building on these existing groups.
They were also successful because they reached out to obtain external resources,
as we said, from UNICEF and from the local government.
They were able to identify the needs of members and set up the savings
cooperatives so the people could see some benefit of membership.
They were able to identify and solve problems.
And, as we mentioned, those that were, the most successful in terms of carrying
out these activities clearly had a heightened sense of community efficacy
and have gone on to elect new leaders, continue to function, and look like they
will be sustainable into the future.
