On July 7, Adjokouma Alakourou was formally presented to her community as their new Community Health Worker. In a ceremony at the Chief’s home, attended by the entire village, Issa Djadjassou, Chief of the village of Kabou-Sara, formally handed Adjokouma her new backpack. Equipped with everything she needed to provide a full pediatric consultation in the home, Adjokouma put on the backpack and began her first day on the job as a new Community Health Worker.
Building ownership takes time
The preparation for this day began long before the ceremony at the Chief’s home. In fact, it began in Kabou-Sara more than six months earlier, when a team from Integrate Health, alongside local Ministry of Health clinic staff, first sat down with the Chief to talk to him about what they could do together to help to improve healthcare in the community.
In the months leading up to Integrate Health beginning to support healthcare delivery in a new community, an extensive process unfolds. Meetings with key stakeholders, including clinic staff, traditional leaders, women’s groups, and the community itself, help us understand local community needs, how these may resemble or differ from other communities where we work, and what can be addressed together to better meet the needs of this community. These discussions are lively, and each voice is heard intently, only sometimes drowned by the cries of the many children who also attend the meetings, wrapped on the backs of their mothers — future beneficiaries of improved healthcare delivery.
Overall, this consultative process, including community-led recruitment of a new cadre of female Community Health Workers, takes roughly six months. While this might seem laborious or even unrelated to the work of providing healthcare, it is anything but. This process builds the social compact that is necessary for lasting change. At Integrate Health, we believe deeply that the process of strengthening the health system must begin with, be led by, and be accountable to community members themselves.
Building ownership means valuing local knowledge
One of the most important ways that international organizations, like Integrate Health, can demonstrate their respect for the local community is to leverage, rather than seek to replace, existing systems. The systems and processes that predate a new program or intervention and that were built and are owned by the local community are invaluable resources. In our work, Integrate Health seeks to leverage these systems, rather than seek to ignore or replace them. For example, traditional healers figure prominently in our efforts to ensure rapid access to quality care for all.
Alougou Makpete has been serving the community of Sarakawa since the age of 15. Using medicinal plants and herbs, he has provided a first line of healthcare to his community in an area where access to quality health services was virtually non-existent. In 2015, Makpete attended a series of community meetings where he learned that the Ministry of Health, alongside Integrate Health, would soon be making new investments to strengthen the healthcare system in his community of Sarakawa. Unsure of what this would mean for his role in the community, Makpete was astonished when Emile Bobozi, Program Director at Integrate Health, reached out to him. Emile wanted to know if the traditional healer network in Sarakawa, of which Makpete was the informal leader, would become a partner in this effort. Makpete recalls, “My role has always been to improve the health of my neighbors. If there was more I could do to realize that goal, I wanted to do it.” Emile explained that the Ministry of Health and Integrate Health were interested in training the traditional healers of Sarakawa, along with three other communities, on the identification of danger signs. Learning to identify these danger signs would help Makpete and his fellow traditional healers distinguish between cases that they could treat and those necessitating rapid referral to a clinic or a trained Community Health Worker in order to save a patient’s life. With Makpete’s help to mobilize the traditional healer network, over 230 traditional healers across nine communities have received this training to date.
Not only was this process of inclusion validating to the traditional healers, it has proved integral to the success of Integrate Health’s approach. Traditional healers routinely refer patients to clinics and Community Health Workers, sometimes carrying a child themselves to the home of a Community Health Worker in the middle of the night. Moreover, this process has served to embed the leadership and responsibility for the strengthening of the healthcare system in community systems and leaders who predated and will outlast any external support.
Building ownership promotes accountability
In addition to formalizing the process of securing local buy-in and leveraging existing community systems, Integrate Health believes that healthcare services must remain accountable to the community, in perpetuity. One of the mechanisms through which we operationalize this belief is by holding bi-annual community town hall meetings. At the invitation of the Chief, which extended to the entire community, representatives from the local Ministry of Health and Integrate Health staff gathered beneath a mango tree, seated in a wide circle to discuss the issues that most confront the community. Progress and challenges were shared, and feedback was sought to help the healthcare delivery team and our Integrate Health support team understand what was happening in the community on a daily basis and how we could improve. This was not an abstract discussion. Our team presented numbers and program indicators, often drawn as run charts on flip chart paper held up high for all to see under the mango tree. We asked the community to help us interpret the trends we were seeing in the data. Sometimes, this necessitated a brief public health lesson: for example, on how contraceptive coverage rate is calculated. But the insights garnered from these discussions, which directly inform our work to improve the quality of care delivered, are invaluable to our team and to the public sector’s clinic staff.
These meetings don’t just inform our efforts; they serve an important accountability function between the community and the public healthcare system. A recent community meeting held on May 15, 2019 in the village of Kabou-Sara was attended by the District Health Director. Empowering community members, especially those who live in remote, rural communities, to share their concerns directly with their leaders helps to build ownership over the health system in their community. Holding ourselves and our government partners accountable to these community members is an absolutely necessary component of building lasting change.
Building ownership grounds everything we do
Integrate Health was created by a committed group of community activists who refused to accept that their HIV status was a death sentence. They organized, they rallied, they fought, and they made changes system-wide that are still resonating today. I mention this history to make it clear that as an organization, ownership is not just a research-based concept, but the very fabric of our being as an organization.
Building community ownership is a belief that we act on in every community that we have the pleasure to serve. System-wide change should not be imposed from above, but must be created and cultivated on the ground, at the grassroots, by the community itself. Community consultations, community health workers, traditional healer trainings, and town hall meetings — these things are not model adjacent, but the core of the model itself. Building community ownership is how lasting transformations in healthcare delivery always have and will continue to occur.