Since 2013 we have looked at why health care is failing communities in difficult social circumstances, such as poverty and exclusion.
By spending time with almost 100 practitioners, we’ve come to appreciate that working with these communities requires starting from their priorities, only one of which is health. We have gleaned 12 over-arching principles for how to do this. Together, they describe an inclusive, participatory and responsive process.
Along the way, we have learned that the process has the potential to foster the ‘agency’ of communities – their ability to make purposeful choices. This ability is core to having a sense of control, which is fundamental to health. In fact, risk factors – whether personal, environmental or social – cannot fully explain why people are healthy or sick. The missing link is whether people have a sense of control.
We help health care change its way of working to be more inclusive, participatory and responsive.
Not only can this new way of working foster the agency of communities, it also enables health care to reconceive its role with the communities it serves. Health care must move beyond deploying technical solutions for acute illnesses and trauma. It must learn to support people and communities to define and shape their own health.
The 12 Principles
- Include in a community’s collective effort those who live there, those who work there, and those who deliver or support services provided there
- Spend time understanding differences in context, goals and power
- Appreciate the arc of local history as part of the story of a place
- Elicit, value and respond to what matters to community residents
- Facilitate and support the sharing of power, including building the capacity to use it and acknowledging existing imbalances
- Operate at four levels at the same time: individual, community, institutional and policy
- Accept that this is long-term, iterative work
- Embrace uncertainty, tension and missteps as sources of success
- Measure what matters, including the process and experience of the work
- Build a vehicle buffered from the constraints of existing systems and able to respond to what happens, as it happens
- Build a team capable of working in a collaborative, iterative way, including being able to navigate the tensions inherent in this work
- Pursue sustainability creatively; it’s as much about narrative, process and relationships as it is about resources
The work that informed the Principles is listed below.
Our March 2018 report brings together what we have done since our 2017 report, including our symposium, recruiting pilot sites to apply the principles to their practice, delivering our message to the health sector, and engaging health philanthropy. We have learned that the importance of agency to health is poorly appreciated within health care, and that the 12 Principles provide the sector with a framework for change, especially through their efforts to engage communities.
Our tool helps you embrace and apply the way of working that is described through the 12 Principles. Each principle is accompanied by a series of descriptions of what it would look like to be aligned with that principle, as well as a series of questions to help you assess what you might do differently. It includes a step-by-step illustration of how a health system might consider the principles within a community health partnership to integrate chronic disease management and social needs screening.
Our May 2017 symposium, Community Agency & Health, explored the potential of community agency. A report of the symposium was included as part of our March 2018 report. The program is available online. Many of the presenters described their work ahead of the symposium (see series), and many of the participants shared their reflections afterwards (see series), including sharing some resources and tools. The symposium’s major sponsors were The California Endowment, Kaiser Permanente & RWJF.
Our March 2017 report includes a detailed rationale for each of the 12 Principles, abstracts of the presentations from the Creating Health Collaborative's 2016 meeting (see below), a description of the evidence linking agency to health, and a series of commentaries on our April 2016 report in which we described 11 principles. The report also explains why we stopped using the term ‘creating health’ and illustrates how the principles have evolved since we started in 2013.
Published September 2015, our eBook, Communities Creating Health (Amazon), explored what would happen if the design, implementation and evaluation of health interventions became something we did with communities rather than to them. Co-published with Stanford Social Innovation Review, the articles brought together the voices of community members, implementers, evaluators, and funders, and built on a meeting hosted by the Institute of Medicine in August 2014 on how evaluations in health can align more closely with what communities value.
We call the practitioners that we've spent time with the 'Creating Health Collaborative'. All of its members have three things in common: their work is based on a community's understanding of its health; their insights are based on practice, not theory; and they're willing to share their struggles as much as their successes, either through writing or by participating in our invitation-only meetings held in New York and hosted by Loeb & Loeb. To date, we have held three meetings (in 2014, 2015 and 2016), and each were limited to 20 participants.