Community engagement and local governance for health equity …

Community engagement and local governance for health equity …

Empowering Communities, Strengthening Local Governance

Community engagement and local governance are essential components of effective health interventions aimed at empowering local populations and addressing health inequities. However, there is limited evidence on how to meaningfully engage with communities and co-develop sustainable initiatives, especially in diverse, resource-constrained contexts like Southeast Asia.

The case of the Lao People’s Democratic Republic (Lao PDR) provides valuable insights into developing an innovative community engagement approach that strengthens local governance for health equity. Despite rapid progress, Lao PDR still faces significant challenges in maternal and child health, with essential service coverage showing disparities across socioeconomic strata. The COVID-19 pandemic exacerbated these long-standing issues, highlighting the need for a coordinated, multisectoral response that engages local communities.

In response, the Lao PDR government, supported by the World Health Organization (WHO) and partners, developed the Community Network Engagement for Essential Healthcare and COVID-19 Responses through Trust (CONNECT) Initiative. This article explores the iterative, adaptive process through which CONNECT was co-created, the key stakeholders and components, the theory of change, and the lessons learned. As a model that can be adapted to other settings, CONNECT provides evidence on effectively engaging communities, strengthening local governance, and co-developing interventions towards greater health equity.

The Evolving Process of CONNECT’s Development

The development of CONNECT involved an iterative process of observations, hypotheses, and interventions, grounded in the realities of the local context. This approach aimed to build on existing structures and relationships, rather than imposing a top-down, externally driven program.

Recognizing Entry Points and Existing Structures

Prior to the COVID-19 pandemic, efforts to improve primary healthcare (PHC) through community engagement in Lao PDR had limited sustainable impact, often focusing on technical solutions rather than addressing governance challenges. The pandemic, however, created a window of opportunity to strengthen local governance and community engagement for health.

During the COVID-19 response, the critical role of provincial and district governors in leading multisectoral collaboration and community mobilization became evident. This demonstrated the importance of engaging local government authorities beyond the health sector to tackle community health issues. “Comparison of how the health governance structure is often perceived by development partners and the actual system in Lao PDR” (Figure 1) illustrates this misalignment, where the health sector has limited authority over and accountability from the community.

“Recognizing that social determinants of health could be addressed by other sectors impacted solution development at the community and subnational levels. Adapting to the governance structure and addressing gaps in local government engagement was critical for developing a rapid pandemic response.”

By aligning CONNECT with the existing “Three Builds” technical decentralization policy, which outlines the responsibilities of local government, including health, the initiative was able to attract political commitment and secure funding support from the Ministry of Home Affairs (MoHA) and the Ministry of Health (MoH).

Building Relationships and Trust

Rather than starting with a pre-conceived program design, CONNECT prioritized developing productive partnerships between stakeholders during the design process, allowing each to provide ongoing input and take ownership of the initiative.

The team recognized that poor trust in health providers and lack of established relationships had negatively impacted health service utilization in the past. To address this, CONNECT explicitly aimed to establish equitable partnerships and prioritize the needs and ideas of those with less power, such as vulnerable community members.

“An important aspect was creating a safe, trusting space where community members and health providers could acknowledge strengths and challenges and find collective solutions. These safe spaces were fostered through trust-building games, village mapping, home visits and other participatory activities, prepared through training government staff facilitators.”

By focusing on building positive, non-hierarchical relationships and mutual respect, CONNECT was able to foster an environment where stakeholders could engage in genuine dialogue and collectively identify solutions. This adaptive, grounds-up approach, rooted in understanding the local context, was critical for sustainable community engagement.

Iterative Development and Monitoring

The development of CONNECT’s core components, key stakeholders, theory of change, and evaluation framework evolved through a continuous cycle of observations, hypotheses, and interventions (Figure 3). This process involved government partners, technical support from WHO and the United Nations Development Programme (UNDP), and feedback from community members and local officials.

For example, initial research and field observations identified the crucial role of trust in essential healthcare utilization. This led to the hypothesis that a trust-building approach would result in more effective community engagement and improved service uptake, which was then translated into the design of specific trust-building activities and principles.

“By collecting feedback and suggestions from community members and local government staff through interviews, discussions and observation during workshops, the team was able to adjust and refine the approach to be more responsive to local needs and priorities.”

The resulting monitoring and evaluation framework encompasses a diverse range of quantitative and qualitative indicators, acknowledging that change can be both tangible and intangible. This allows CONNECT to capture the broader impacts on health equity, including unexpected outcomes, and continuously refine the intervention based on feedback and emerging evidence.

The CONNECT Approach: Key Components and Guiding Principles

CONNECT is structured around three core modules that target governance and health sectors at all levels, along with community representatives. These modules are underpinned by six guiding principles that shape the initiative’s approach to community engagement and local governance.

The CONNECT Modules

  1. Strengthening Local Governance: This module engages provincial and district governors to support, sustain, and scale up community engagement for health. It aims to leverage the role of local government authorities in leading multisectoral collaboration and community mobilization, as seen during the COVID-19 response.

  2. Building Trust and Local Ownership: This is the core of the CONNECT approach, involving a 2-day participatory planning workshop at the community level. Through a series of activities designed to break down hierarchies, build trust, and identify local resources and strengths, the workshop culminates in the development of a community-led action plan.

  3. Building Capacities of Healthcare Providers: This module focuses on supporting healthcare providers to develop relational care skills, counseling techniques, and a deeper understanding of community priorities and needs. This helps to foster trust and mutual accountability between providers and community members.

These modules are supported by an ongoing process of policy dialogue and adaptation at the national level, aimed at identifying, developing, and implementing pro-equity policies and regulations to sustain the impact of CONNECT.

Six Guiding Principles

The CONNECT approach is underpinned by six core principles that are enacted and practiced through all activities:

  1. Building Trusting Relationships: Prioritizing the development of positive, non-hierarchical relationships and mutual respect among all stakeholders.

  2. Positive Approach to Identify and Enhance Potential: Focusing on community assets and strengths, rather than deficits, to foster motivation and ownership.

  3. Respecting and Supporting Community Ownership: Empowering communities to lead the planning and implementation of health actions.

  4. Active Empathetic Listening: Encouraging genuine curiosity and understanding of local knowledge, experiences, and perceptions.

  5. Non-Hierarchical, Two-Way Communication: Creating safe, inclusive spaces for open dialogue and joint problem-solving.

  6. Caring with Mutual Respect and Genuine Interest: Cultivating an ethic of care and shared responsibility for community health.

These principles are introduced during the facilitator training and enacted through practical actions, such as rearranging meeting room formats, using informal speech, and including interactive games. This helps to address power differentials and foster a shared values framework among all stakeholders.

Lessons Learned and Implications for Other Settings

The development of CONNECT has yielded valuable lessons that can inform community engagement and local governance initiatives in other contexts:

  1. Identifying Entry Points and Existing Structures: Understanding the local governance landscape and aligning with relevant policies and mandates is crucial for securing political commitment and sustainable funding. Recognizing the role of local government authorities beyond the health sector can help to address underlying governance challenges.

  2. Building Relationships and Trust: Prioritizing the development of positive, non-hierarchical relationships and mutual trust is essential for effective and sustainable community engagement. An adaptive, grounds-up approach that incorporates community feedback and empowers marginalized groups is more likely to lead to genuine ownership and lasting change.

  3. Adaptability and Scalability: While CONNECT has primarily focused on COVID-19 responses and maternal and child health in rural Lao PDR, its flexible design and guiding principles suggest that it may be applicable to other health programs and contexts. However, careful testing and adaptation are required to ensure relevance to different populations, socioeconomic settings, and political contexts.

  4. Integrating Health and Governance Indicators: By incorporating governance-related indicators, such as birth registration, into the monitoring and evaluation framework, CONNECT has been able to demonstrate the mutual benefits of cross-sectoral collaboration and foster shared accountability between the health and governance sectors.

As an adaptable model, CONNECT provides a case study for effective community engagement, strengthening local governance, and co-developing interventions towards greater health equity. Continued analysis of monitoring data and further research will be crucial in determining the nationwide and long-term impact of this approach in Lao PDR and beyond.

To learn more about the Joint Action for Water initiative and access additional resources, please visit https://jointactionforwater.org/.

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