Willing but unable? Extending theory to investigate community capacity to participate in Ghana’s community-based health planning and service implementation
Introduction
In Low and Middle Income Countrieswhere centrally controlled health programmes often fail to make significant impact, community participation is seen as the way to make health systems results oriented (Rifkin, 2014; Rosato, Laverack, & Grabman, 2008). Community participation although an age-old concept associated with the 1978 Alma Ata proclamation of primary health care, has remained relevant in contemporary global health policy discourse (Draper, Hewitt, & Rifkin, 2010; Rosato et al., 2008). Within the last decade, for example, community participation has been revitalised by a number of international health policy initiatives – the Millennium Development Goals, the Every Newborn Action Plan, the Integrated Management of Childhood Illnesses among others that strongly encourage strong community involvement in promoting health and well-being (Juma, Owuor, & Bennett, 2015; Rosato et al., 2008). Such global initiatives were necessitated by evidence showing primary health care founded on community participation results in quality and cost-effective health service delivery (Morgan, 2001), and that targeted programmes and strategies designed to improve maternal, child and newborn survival and tackle disease burden of the poor triumphed with community involvement (Lewin, Lavis, & Oxman, 2008; Rifkin, 2014; Rosato et al., 2008).
Community participation has traditionally been viewed from the lens of utilitarian (participation as a means to and end) and empowerment (participation as an end in itself) in pursuing social change (Morgan, 2001; Pérez, Lefèvre, & Romero, 2009). Central to both traditions of participation is that the community acts as an agent in defining, diagnosing and prioritising solutions to problems confronting health (McLeroy, Norton, Kegler, Burdine, & Sumaya, 2003). While scholars remain polarised on the specific mechanisms that can be deployed to maximise participation from the utilitarian and empowerment lens (Pérez et al., 2009), there is somewhat consensus that participation as a means to attaining prescribed programme goals is influenced by the capacity to participate in driving such efforts, and in providing inputs to sustain gains into the long term (Rifkin, 2014).
Community capacity has been given diverse interpretations, creating confusion about its precise meaning. Nonetheless, despite the many definitions proffered (see for example: Goodman, Speers, & McLeroy, 1998; Laverack, 2005; Wendel, Burdine, & McLeroy, 2009), they seem unified in Chaskin’s (2001: 4) definition of community capacity as ‘…a community’s human, organisational and social capital that can be leveraged to solve collective problems, and improve or maintain well-being; it may operate through informal social processes and/or organised efforts by individuals, groups, networks of associations and the broader system of which the community is part’. From this point of view, capacity is seen as the bedrock of a functional community participation as it determines the ability to mobilise, network and collectively solve health problems.
The capacity to participate in health is reported to have profound benefits. Notably, it motivates actions in addressing problems of programmes implementation (Hickey & Mohan, 2004; Mansuri & Rao, 2004), offsets cost of health delivery, increases broad-based support and health service use, thereby improving confidence in the health system (Alfonso, Nickelson, & Hogeboom, 2008; Millar, Robertson, & Allender, 2013). Alfonso et al. (2008) and Goodman et al. (1998) highlighted the importance of capacity; noting it is linked to programme ownership, where community members act as champions to communicate goals, motivate each other, obtain resources and spearhead implementation. Systematic efforts by international bodies including the World Bank, UNICEF and World Health Organisation to devolve some elements of management and delivery of health services to the community (Bhutta, Ahmed, & Black, 2008), means that capacity cannot be ignored in health programmes scale up, and doing so will be problematic as real life implementation decisions and actions are tied to the individual and collective will to participate in providing needed support systems.
While knowledge on the importance of community capacity proliferates, empirical evidence on whether and to what extent local people have the capacity to participate and support community-based health programmes implementation is poorly documented. This has created room for multiplicity of assumptions regarding what a capable community is (Gibbon, Labonte, & Laverack, 2002; Goodman et al., 1998; Wendel et al., 2009), further comprising empirical endeavours of this important field. Researchers have theorised indicators of community capacity ostensibly to minimise speculations surrounding the concept – but studies testing these indicators in health programmes context are not only few (Draper et al., 2010; Gibbon et al., 2002; Laverack, 2005), but that they have been conducted outside the context of sub-Saharan African (SSA), which is home to a significant number of community-based interventions (Rosato et al., 2008). Also, such studies clearly lack sufficient empirical and subjective measures of capacity from the community’s own perspective. The knowledge vacuum is often a barrier to SSA governments and health stakeholders’ efforts at making informed decisions on building capable communities for participation in health programmes.
This study sought to contribute to the knowledge gap by drawing on theory to empirically assess the level of community capacity to participate in Ghana’s community-based health planning and service (CHPS) programme implementation. CHPS is a national primary care programme modelled on the Alma Ata primary health care tenets – community participation, inter-sector partnership and use of cost effective local resources (Lawn, Rohde, & Rifkin, 2008). CHPS emerged from a successful community trial in northern Ghana in the late 1990s targeting reduction in maternal and childhood mortalities. It was subsequently integrated into the health system as a primary health care policy with nationwide scale up in 2002 (Nyonator, Awoonor-William, Phillip, Jones, & Miller, 2005). CHPS implementation requires active involvement of the district health managers, community members and community-based health providers. Within the community, CHPS relies on voluntarism, supportive leadership, social mobilisation and local resource support to deliver health services at scale (Fig. 1) (Nyonator et al., 2005). Detailed information about CHPS can be found elsewhere (Awoonor-Williams, Sory, & Nyonator, 2013; Nyonator et al., 2005; Phillips, Bawah, & Binka, 2006). To our knowledge this study is the first to assess community capacity to participate in CHPS, and it comes at a crucial time where government and international partners are seeking evidence to strengthen community involvement in its implementation. Thus, findings will drive policy efforts on maximising community capacity to participate in the programme.
Section snippets
Theoretical framework
This study drew upon Chaskin (2001) theory of community capacity to assess the level of community capacity to participate in CHPS. Chaskin theorised four indicators of community capacity: sense of community; commitment among community members; mechanisms of problem solving; and access to resources. Sense of community describes the nature and quality of social ties for mutual benefits. It is determined by mutual concern for community issues, shared values as well as norms that propel common
Demographic characteristics of participants
Demographic characteristics of participants are shown in Table 2. Participants in the qualitative study were older ( = 37) than those in the quantitative study ( = 32). The majority of participants in both studies had no formal education and farming was the main occupation.
Community capacity to participate in CHPS
This section presents findings of both the qualitative and quantitative data on the capacity to participate in CHPS applying Chaskin (2001) community capacity indicators: sense of community (shared values and social
Discussion
CHPS is more than just a medium of health service delivery. It encompasses community participation, mobilisation and social support systems in reducing cost of care delivery and promoting social accountability mechanisms in health governance at the micro level (Nyonator et al., 2005). As participation is paramount to sustainable CHPS implementation in achieving target objectives, this study sought to determine whether and how local people have the capacity to participate in it, with the
Conclusion
Policy makers seeking strategies to strengthen CHPS implementation can benefit from the study’s findings in a number of ways. First, since social capital is important for building and sustaining community values towards mutual beneficial relationship (Woolcock, 2001), we suggest the initiation of strong community networking programmes that will allow for formal and informal meetings and promotion of horizontal collective action. Brune and Bossert (2009) noted how such networks helped build
Conflict of interest
None.
Funding
This study received support from the African Doctoral Dissertation Research Fellowship by the African Population and Health Research Centre, Nairobi Kenya (Grant number: 2014-2016 ADF 001) for the first author’s doctoral thesis work. The Centre played no role in the development and writing of this manuscript.
Acknowledgements
We are deeply grateful to all the field assistants for their immense efforts during the data collection process. We would also like to thank the District Health Directors and all the participants for making time to participate and provide invaluable information for the study.
References (40)
- et al.
Assessing local capacity for health intervention
Evaluation and Program Planning
(2008) - et al.
What works? Interventions for maternal and child undernutrition and survival
The Lancet
(2008) - et al.
Building social capital in post-conflict communities: Evidence from Nicaragua
Social Science & Medicine
(2009) - et al.
Chasing the dragon: Developing indicators for the assessment of community participation in health programmes
Social Science & Medicine
(2010) - et al.
Social capital and access to primary health care in developing countries: Evidence from Sub-Saharan Africa
Journal of Health Economics
(2016) - et al.
Alma-Ata 30 years on: Revolutionary, relevant, and time to revitalise
Lancet
(2008) - et al.
Supporting the delivery of cost-effective interventions in primary health-care systems in low-income and middle-income countries: An overview of systematic reviews
Lancet
(2008) - et al.
Increasing community capacity and decreasing prevalence of overweight and obesity in a community based intervention among Australian adolescents
Preventive Medicine
(2013) Lessons from community participation in health programmes: A review of the post Alma-Ata experience
International Health
(2009)- et al.
Community participation: Lessons for maternal, newborn, and child health
Lancet
(2008)
Defining community capacity building: Is it possible?
Preventive Medicine
Implementing CHPS today: Propositions from the Ghana health service
Paper presented at the national CHPS forum on the theme: Public-private dialogue for a new policy direction for community health service
Lessons learned from scaling up a community-based health program in the Upper East Region of northern Ghana
Global Health: Science and Practice
Building community capacity
Urban Affairs Review
Designing and conducting mixed methods research
Qualitative and mixed methods provide unique contributions to outcomes research
Circulation
Ghana living standard survey 6
Evaluating community capacity
Health & Social Care in the Community
Identifying and defining the dimensions of community capacity to provide a basis for measurement
Health Education & Behavior
Cited by (16)
Community capacity influencing community participation: Evidence from Ethiopia
2022, World Development PerspectivesCitation Excerpt :It is, therefore, important to identify which dimensions of community capacity influence community participation so that community participation can be enhanced. Although several studies (Akamani & Hall, 2015; Atinga et al., 2019; Aref & Redzuan, 2009; Dorsner, 2004; Howard-Grabman et al., 2017) have investigated participation of residents in externally designed community development projects, studies on other forms of community participation in the developing world are limited. Most of the previous research pertaining to community capacity (Lovell et al., 2011; 2015; Maclellan-Wright et al., 2007; Moreno et al., 2017; Pavey et al., 2007) have also been qualitative in nature, based mainly on data from focus group discussions and key informant interviews, and drawing on the views of community leaders and experts.
Assessing the interactions of people and policy-makers in social participation for health: an inventory of participatory governance measures from a rapid systematic literature review
2023, International Journal for Equity in Health