Abstract
BACKGROUND: While community participation is an established pro-equity approach in Primary Health Care (PHC), in practice it can take many forms, and the central category of power is under-theorised. The objectives of this paper were to (a) conduct theory-informed analysis of community power-building in PHC in a setting of structural deprivation and (b) develop practical guidance.
METHODS: Stakeholders representing rural communities, government departments and non-governmental organisations engaged through a participatory action research (PAR) process in a rural sub-district in South Africa. Three reiterative cycles of collective evidence generation, analysis, action, and reflection were progressed. Local health concerns were raised and framed by rural community stakeholders, who generated new data and evidence with researchers. Dialogue and learning were developed between the authorities and communities, with local action plans coproduced, implemented, and monitored. Throughout, efforts were made to shift and share power, and to adapt the process to improve practical and local relevance. We analysed participant and researcher reflections, project documents, and other project data using power-building and power-limiting frameworks.
RESULTS: Co-constructing evidence among community stakeholders in ‘safe spaces’ for dialogue and cooperative action built collective capabilities. The authorities embraced the platform as a space to safely engage with communities and the process was taken up in the district health system. Responding to COVID-19, the process was collectively re-designed to include a training package for community health workers (CHWs) in rapid PAR. New skills and competencies, new community and facility-based alliances and explicit recognition of CHW roles, value, and contribution at higher levels of the system were reported following the adaptions. The process was subsequently scaled across the sub-district.
CONCLUSIONS: Community power-building in rural PHC was multidimensional, non-linear, and deeply relational. Collective mindsets and capabilities for joint action and learning were built through a pragmatic, cooperative, adaptive process creating spaces where people could create and use evidence to make decisions. Impacts were seen in demand for implementation in outside the study setting. We offer a practice framework to expand community power in PHC: (1) prioritising community capability-building, (2) navigating social and institutional contexts and (3) developing and sustaining authentic learning spaces.
METHODS: Stakeholders representing rural communities, government departments and non-governmental organisations engaged through a participatory action research (PAR) process in a rural sub-district in South Africa. Three reiterative cycles of collective evidence generation, analysis, action, and reflection were progressed. Local health concerns were raised and framed by rural community stakeholders, who generated new data and evidence with researchers. Dialogue and learning were developed between the authorities and communities, with local action plans coproduced, implemented, and monitored. Throughout, efforts were made to shift and share power, and to adapt the process to improve practical and local relevance. We analysed participant and researcher reflections, project documents, and other project data using power-building and power-limiting frameworks.
RESULTS: Co-constructing evidence among community stakeholders in ‘safe spaces’ for dialogue and cooperative action built collective capabilities. The authorities embraced the platform as a space to safely engage with communities and the process was taken up in the district health system. Responding to COVID-19, the process was collectively re-designed to include a training package for community health workers (CHWs) in rapid PAR. New skills and competencies, new community and facility-based alliances and explicit recognition of CHW roles, value, and contribution at higher levels of the system were reported following the adaptions. The process was subsequently scaled across the sub-district.
CONCLUSIONS: Community power-building in rural PHC was multidimensional, non-linear, and deeply relational. Collective mindsets and capabilities for joint action and learning were built through a pragmatic, cooperative, adaptive process creating spaces where people could create and use evidence to make decisions. Impacts were seen in demand for implementation in outside the study setting. We offer a practice framework to expand community power in PHC: (1) prioritising community capability-building, (2) navigating social and institutional contexts and (3) developing and sustaining authentic learning spaces.
| Original language | English |
|---|---|
| Article number | 94 |
| Number of pages | 22 |
| Journal | International Journal for Equity in Health |
| Volume | 22 |
| DOIs | |
| Publication status | Published - 17 May 2023 |
Bibliographical note
AcknowledgementsThe authors would like to thank community, government, and non-governmental stakeholder participants for agreeing to be part of the process, and for sharing their time, knowledge, and perspectives. Thanks also to the Verbal Autopsy with Participatory Action Research (VAPAR) team and staff of the Medical Research Council (MRC)/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), especially Simon Khoza, Sizzy Ngobeni, Ella Sihlangu and Rhian Twine.
Funding
The study is funded by the Joint Health Systems Research Initiative from the Department for International Development/MRC/Welcome Trust/Economic and Social Research Council (MR/P014844/1). The work is nested within the MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), supported by the University of the Witwatersrand and Medical Research Council, South Africa. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Keywords
- community participation
- participatory action research
- power
- South Africa
Access to Document
- Mabetha_etal_IJEH_Realising_Radical_Potential_VOR
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