Representatives of over seventy national, regional and global civil society organisations met at the CIVICUS World Assembly held in Montreal, Canada, on 11 September 2011. A number of key points arose from the meeting including the need for civil society leadership to frame the discussion and guide the process on the post-2015 global agenda, and the need for a new global vision for the people and the planet that is radical, ambitious and universal. The vision should be strongly rooted in and use International Human Rights instruments as the basis for accountability, and should also be universal in its application across the north and the south and address the redistribution of wealth. It should empower communities on the ground to claim their entitlements and should aim at equity, with explicit commitments towards women and traditionally excluded groups. Furthermore, the vision should be holistic and address the issues of human rights, inequality, gender justice and environmental sustainability. Participants at the Assembly called on the United Nations (as opposed to other global fora such as the G20) to lead the process, with the UN Secretary General providing personal leadership on the post-2015 agenda. Until the end of 2015, civil society will aim to work together to develop a unifying, coherent global agenda and take action to influence the positions of national governments and the UN, participants concluded.
Governance and participation in health
There is now wide recognition that community responses must play an increasing role in addressing the HIV epidemic in the years ahead. The UNAIDS Strategic Investment Framework, published in 2011, identifies community responses as a “critical enabler” of service delivery. The Joint United Nations Programme on HIV/AIDS (UNAIDS) has estimated that to achieve bold HIV treatment and prevention targets set in 2014, investments in community mobilisation and services must increase more than threefold between 2015 and 2020. Much of the critically important work in making progress in the response to HIV and implementing a Fast-Track approach that lies ahead—including broadening the reach of services, supporting retention in care, increasing demand, monitoring quality, advancing human rights and combatting stigma and discrimination—can only be achieved with a strong community voice and presence. This report draws on multiple sources to document the many ways in which communities are advancing the response to AIDS, and the evidence for the effectiveness of these responses. Core areas of community-based activities include advocacy, service provision, community- based research and financing; each of these areas is illustrated by examples of community- based actions.
Community Working Group on Health and TARSC. Editors: M. McCartney and R. Loewenson. November 2001
The story of the first years of the Community Working Group on Health in Zimbabwe, describing how the CWGH surveyed and met with over 20 membership-based community groups across Zimbabwe in 1997, to identify the major community concerns about health, and to devise effective strategies for dealing with them. Providing a concise and comprehensive overview of the issues facing the health sector in Zimbabwe, problems associated with community participation, and a discussion of the best strategies for community based advocacy and action.
This study assessed community acceptability of the use of rapid diagnostic tests (RDTs) by Ugandan CHWs, locally referred to as community medicine distributors (CMDs). The study was conducted in Iganga district using 10 focus group discussions (FGDs) with CMDs and caregivers of children under five years, and 10 key informant interviews (KIIs) with health workers and community leaders. The study found that CMDs are trusted by their communities because of their commitment to voluntary service, access, and the perceived effectiveness of anti-malarial drugs they provide. Some community members expressed fear that the blood collected could be used for HIV testing, the procedure could infect children with HIV, and the blood samples could be used for witchcraft. Education level of CMDs is important in their acceptability by the community, who welcome the use of RDTs given that the CMDs are trained and supported. Anticipated challenges for CMDs included transport for patient follow-up and picking supplies, adults demanding to be tested, and caregivers insisting their children be treated instead of being referred. Use of RDTs by CMDs is likely to be acceptable by community members given that CMDs are properly trained, and receive regular technical supervision and logistical support.
This paper examines the cultural and structural difficulties surrounding effective prevention of mother-to-child HIV transmission (PMTCT) in rural Lesotho. It argues for three strategies to improve PMTCT interventions: community-based research and outreach, addressing cultural and structural dynamics, and working with the relevant social groups that impact on HIV prevention. These conclusions are based on interviews and participant observation conducted within the rural Mokhotlong district and capital city of Maseru, involving women and men of reproductive age, grandmothers serving as primary caretakers, HIV and AIDS programme staff and medical professionals. Qualitative analysis focused on rural women's socio-medical experience with the four measures of PMTCT (educational outreach, voluntary counselling and testing, antiretroviral interventions and safe infant feeding). Based on these results, the paper concludes that intervention models must move beyond a myopic biomedical ‘best-practices' approach to address the social groups and contextual determinants impacting on vertical HIV transmission. Given the complexities of effective PMTCT, our results show that it is necessary to consider the biomedical system, women and children, and the community as valuable partners in achieving positive health outcomes.
Civic organisations have through the monitoring Group of the National NGO Food Security Network (FOSENET) been monitoring food security in Zimbabwe since July 2002. In 2004 this monitoring has been widened to cover other social and economic conditions, recognizing the wide range of conditions influencing social and economic wellbeing. The Civic Monitoring Programme is implemented through NGOs based within districts and community based monitors. Monthly reports from all areas of the country are compiled to provide a monthly situation assessment of food security and social welfare to enhance an ethical, effective and community focussed response to the current situation. Quarterly reports such as this one complement the monthly monitoring and provide more detailed information on specific areas of social and economic conditions at community level. Queries and feedback on these reports is welcomed and should be directed to the Civic Monitoring Programme at fsmt2@mweb.co.zw This is the first round of such quarterly monitoring and continuous measures are being implemented to improve data quality and relevance, including training and peer review, so feedback is welcomed. For the full report, please contact fsmt2@mweb.co.zw.
In Uganda, community services for febrile children are expanding from presumptive treatment of fever with anti-malarials through the home-based management of fever (HBMF) programme, to include treatment for malaria, diarrhoea and pneumonia through Integrated Community Case Management (ICCM). To understand the level of support available, and the capacity and motivation of community health workers to deliver these expanded services, the authors interviewed community medicine distributors (CMDs), who had been involved in the HBMF programme in Tororo district, shortly before ICCM was adopted. Between October 2009 and April 2010, 100 CMDs were recruited to participate by convenience sampling. The survey included questionnaires to gather information about the CMDs’ work experience and to assess knowledge of fever case management, and in-depth interviews to discuss experiences as CMDs including motivation, supervision and relationships with the community. CMDs faced multiple challenges including high patient load, limited knowledge and supervision, lack of compensation, limited drugs and supplies, and unrealistic expectations of community members. CMDs described being motivated to volunteer for altruistic reasons; however, the main benefits of their work appeared related to ‘becoming someone important’, with the potential for social mobility for self and family, including building relationships with health workers. At the time of the survey, over half of CMDs felt demotivated due to limited support from communities and the health system. Community health worker programmes rely on the support of communities and health systems to operate sustainably. When this support falls short, motivation of volunteers can wane. If community interventions, in increasingly complex forms, are to become the solution to improving access to primary health care, greater attention to what motivates individuals, and ways to strengthen health system support are required.
I Rusike, R Loewenson, CWGH, TARSC.
Equity in health is a long stated policy goal in Southern Africa, and some significant advances were made often through joint and complimentary action between the public health sector and communities. However, the health and health care gap between communities is still wide or widening, with differences based on gender, geographical area, income, access to public or private services, education and other factors. More recently,the combined impact of AIDS, structural adjustment, and real reductions in the health budget and in household incomes, has reversed many health gains. The quality of health care has declined and health workers and their clients have become demoralised. While these issues demand technical responses, reversing inequities depends in the main on social and political factors. This goes beyond the fact that social networking is important for service outreach and health seeking behaviour, and that social exclusion as a dimension of deprivation or poverty affects health outcomes. What we argue is that unless people affected by ill health have greater control over the resources needed for health care or to be healthy, equity goals will remain a dream. Equity without this socio-political dimension is not equity.
WHO has defined community engagement as “a process of developing relationships that enable stakeholders to work together to address health-related issues and promote well-being to achieve positive health impact and outcomes”. The organisation notes undeniable benefits to engaging communities in promoting health and wellbeing. This guide is intended for change agents involved in community work at the level of communities and healthy settings.
This paper explores whether community participation through health committees can advance the right to health, and what constitutes best practice for community participation through South African health committees. The paper reports on a series of 32 indepth interviews with members of three Community Health Committees and health service providers in the Cape Metropolitan area and provides some valuable insight into these areas. The most prominent barriers to participation mentioned by participants, included underrepresentation of vulnerable and marginalised groups, and the absence of a formal mandate giving Health Committees clear objectives and the authority to achieve them. A number of characteristics of Health Committees were identified that promoted more meaningful participation: a facility manager who helps tip the balance of power from health professionals towards the community by sharing decision-making with the Health Committee and by involving the Committee in facility operations; a form of apprenticeship in which newer Health Committee members learn skills and procedures from more experienced members; intersectoral activity through the regular involvement of ward councillors and environmental health officers in Health Committee meetings and activities; a mechanism for the Health Committee to be involved in the reviewing and resolution of patient-based complaints at health facilities; the use of the media and written sources of information by Committees to increase their visibility in the clinic and in the community, disseminate important health-related information, inform the community of Health Committee activities and broaden participation. Achieving small gains appeared to act as positive reinforcement and strengthen the Health Committees to achieve bigger gains.