Can Community Systems Strengthening Improve Health? A Literature Review


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Presented at the 2012 Global Symposium on Health Systems Research.

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  • Increased attention on the importance of communities to improve service delivery, health outcomes --Global Fund has a strong focus on community systems strengthening (CSS) by building the capacity of community-based organizations (CBO)--USAID – also has a long history of building capacity of CBOs
  • Journals and pre-existing literature reviews have been identified using several search engines such as PubMed, Sociofile, Google Scholar, SCIRUS, Web of Science, Social Science Research Network (SSRN), Anthro Abstracts and JSTOR. Search terms included: community typology, civil society typology, community systems, community response, community structures, and community-based organizations. We explored related concepts: history of civil society, CBOs and other community-based actors and structures; organizational development of community groups; history of donor support; and community empowerment, mobilization, participation, involvement, engagement, collaboration, and partnership. We reviewed definitions of all the common terms. We found over 600 papers and reports that touch on this broad topic, though only a subset of those make it into the present paper.
  • To position CSS within the context of historic and contemporary community level work, we traced the most salient antecedent traditions - these have shaped the intellectual landscape within which CSS has developed. Community-based Approach – roots in the 1930s and 40s, social epidemiology, and community health center movement in South Africa. Fundamentally, the community development movement saw the centralized, top down development systems as rigid, expensive, inappropriate and ineffective at reaching those who most need help. This movement has spawned many traditions itself – from grassroots development, intermediate or appropriate technology, health system decentralization and district rural focus, to various forms of community health strategies (at the national level). Civil Society Strengthening – is often viewed as a strategy to fill in gaps where governments fall short.Much of the present focus on civil society arose in the late 1980’s– a time when civil society was expected to fill the vacuum left by non-existent or declining investment in the public sector – thus, the modern use of ‘civil society’ for most people tends to exclude the state. Concept of “community systems strengthening” probably embodies a continuation of the debate of the role of community structures within the state and in relation to health policy and programs. For example, GFATM was founded on the recognition that weak, under-resourced government health systems are unable to cope with the crises generated with the three epidemics.“Systems thinking” emerged in the early part of the 20th Century from diverse fields in the physical and natural sciences. It provides a way of understanding what is happening within dynamic systems characterized by complexity and non-linearity. Complex systems have the following characteristics: they are made up of interconnected and interdependent elements, they are subject to feedback processes, they have non-linear properties, they exhibit sensitivity to initial conditions, and they are self-organizing (WHO 2009). Most modern health systems, and indeed most community systems, are complex systems.Health System Strengthening – a social institution working with other institutions to promote wellbeing, rather than just providing treatment (Balabanova, McKee et al. 2011). Practitioners commonly use the term health system when referring to services provided by the professional health care system (World Health Organization 2000), often losing the breadth of the comprehensive definition.
  • GFATM definition: “community systems are community-led structures and mechanisms used by … community members and community-based organizations and groups to interact, coordinate, and deliver their responses to the challenges and needs affecting communities” (GFATM 2011)A careful review of CSS documents reveals that there is substantial confusion in language around community and related terms. Often, ‘community’ is used interchangeably with ‘civil society’, or with specific ethnic-, age-, or gender-based identities within civil society. ‘Community-based organization’ may refer to ‘relatively weak organizations operative at a very local level’ to ‘relatively sophisticated entities operating across an region’ (Taylor 2010). The term “NGO” is often used interchangeably with “private voluntary organization” and “non-profit organization” (Costoya 2007).
  • Given the pervasiveness of inconsistencies in how community and related concepts are defined, we begin with a careful definition of “community”. Then, community systems are explored through typologies that have attempted variously to describe their structures, functions and attributes.McLeroy et al. (2003) contribute an additional perspective to this elaboration of “community”. According to the authors, “community-based” takes on different meanings depending upon the particular construction of community that is employed: community as setting, community as target, community as agent, or community as resource. Community as setting recalls the geographically defined community elaborated above. In this construction, the community is the location in which interventions are implemented. In the second construction, community is the target of change. The community as resource construction is aimed at mobilizing a community’s internal resources or assets. The final construction, community as agent, emphasizes respect and reinforcement of the natural adaptive capacities of communities. These various constructions lead to varied strategies of engagement in community-based work.
  • Conceptual Framework–We reviewed 14 health frameworks published between 1994 to present. All aiming to describe community in the context of improving health. Each framework focused on either community structures, community functions, community attributes or a combination of the above.
  • Four of the conceptual frameworks focused on community structures.For example, arecent World Bank effort (Rodriguez-Garcia, Bonnel et al. 2011) characterizes the community response to HIV and AIDS according to six criteria, including the types of organizations and structures implementing the response. The authors recognize different levels of formal institutionalization among community responses.
  • Some of the frameworks we reviewed focused on community functions. For example, Lavalle (2005) uses functions (the types of activities organizations undertake, such as service delivery to individuals, representation of groups or organizations vis-a-vis the state, defining problems as public issues and influence policy debates, etc.), along with the nature of their relationship to their beneficiaries/members, as the basis for categorizing organizations into five categories. EXAMPLE PROVIDED HERE:
  • Authors such as Laverack (2006), Goodman (1998), Eng (1994), and Bartle (2007.) We have provided an example here, Goodman’s Domains of Community Capacity Strengthening for Health Promotion.
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  • Can Community Systems Strengthening Improve Health? A Literature Review

    1. 1. Can Community SystemsStrengthening Improve Health? A Literature Review Mary Freyder, Erin Peacock, Kate Macintyre, and David Hotchkiss This study was funded by the U.S. Agency for International Development (USAID) under terms of Cooperative Agreement GHA- A-00-08-00003-00 (Health Systems 20/20).
    2. 2. Background• Role of communities and community systems strengthening in health systems receiving increased attention• Investments in CSS have sometimes taken place in the absence of defining the actual systems at work in communities• As a result, understanding of what is meant by CSS remains elusive
    3. 3. Purpose• To review two types of literature: – Antecedent traditions that lay the foundation for the current focus on “community” and “CSS” – Typologies that conceptualize community systems and their role on HSS, health outcomes• Aim of review, and an accompanying review of evaluation research, is to develop a CSS evaluation research agenda
    4. 4. Methods• Type of literature reviewed – Peer-reviewed journals: social and management sciences, public health, policy, development – Grey literature: websites of GFATM, World Bank, DFID, USAID, WHO, and others• Search engines and key words• Of 600 publications identified, we selected: – 42 grey and peer-reviewed articles – 14 conceptual frameworks
    5. 5. Antecedent Traditions• Community-based approach• Civil society strengthening• “Systems thinking” and health systems strengthening
    6. 6. “Community Systems Strengthening”• Phrase “CSS” first appeared in GFATM’s Round 8 Call for Proposals – Initially referred to CBO capacity building – Has since been broadened to include • Key affected populations and communities • Community organizations and networks • Public- or private-sector actors• “Community systems are community-led structures and mechanisms used by … community members and community-based organizations and groups to interact, coordinate, and deliver their responses to the challenges and needs affecting communities” (GFATM 2011)• Pervasiveness of inconsistencies in how community and related concepts are defined
    7. 7. Types of Communities• Shared geography• Shared identity – “common characteristics, experiences, interests, concerns or behavior” (Rodriguez-Garcia et al. 2011)• What is “community-based” depends on construction (McLeroy et al 2003) – community as: – Setting (i.e. location) – Target (i.e. health-related behaviors) – Resource (community’s internal resources or assets) – Agent (respect, reinforcement of the natural adaptive capacities of communities)
    8. 8. Frameworks, Typologies• Structures• Functions• Attributes
    9. 9. StructuresFormal and informal institutional arrangements of community-based initiatives – World Bank 2011 Most informal Households, extended family, and neighbors assisting each other e.g., with food, child care, household chores, or home-based care Community leadership e.g., political, religious and traditional leaders Community initiatives e.g., mutual care and support groups, neighborhood associations, savings clubs, informal counseling groups, and traditional support mechanisms such as voluntary labor, some faith-based congregations, and self-help groups such as PLHIV groups Community-based organizations e.g., faith-based programs, community associations Non-governmental organizations and networks (working at local, national and international levels) e.g., faith-based NGOs, intermediaries, national health networks, multi-sectoral collaborative platforms, district level taskforces, interfaith councils, local leadership councils Rights-based organizations and social movements Mass organizations e.g., community branches of women’s or youth organizations, faith-based movements, national networks of PLHIV Most formal Private sector organizations e.g., local businesses, local foundations Government staff and agenciesSource: Rodriguez-García et al. 2011
    10. 10. Functions• GFATM CSS Core Components – Community activities and service delivery – Resources and capacity building – Enabling environments and advocacy – Monitoring, evaluation, and planning – Community networks, linkages, partnerships, and coordination – Organizational and leadership strengthening
    11. 11. Attributes of Community Capacity• Citizen participation• Leadership• Social & inter-organizational networks• Resources• Skills• Sense of community• An understanding of community history• Power• Values• Critical reflection Sources: Goodman et al (1998).
    12. 12. GFATM Framework: Pathways to Health Input Output Impact CC 1: Enabling environments andStrengthening interventions advocacy CC 2: Community networks, linkages, partnerships and coordination CC 3: Resources and capacity building Quality services Health is are available improved at the and used by the community CC 4: Community activities and service delivery community level CC 5: Organisational and leadership strengthening CC 6: Monitoring & evaluation and planning Source: GFATM (2011).
    13. 13. CSS Interventions – encompasses government and civil society• Enabling environment and advocacy – Strengthening CBOs, and networks of CBOs – Village health committees, patient charters – Provider report cards – Behavior change strategies to influence community norms• Community activities and service delivery – Strengthening CBOs – Introduction of community health workers; task shifting – Community-based case management – Community-based health insurance – Conditional cash transfers for individuals and households
    14. 14. Conclusion• Current focus on community systems represents marriage of a community-level focus with a systems perspective – Follows naturally from “systems thinking”• Community systems can be defined by their structures, functions and attributes – can encompass – Both formal and informal structures – Both government and non-government entities
    15. 15. Thank you!