Fostering community agency isn't a new field of practice. But it's new to many working in health. Embracing its potential will require committing to a different way of working.
Health care costs continue to rise dramatically. Yet for many, outcomes remain poor, health disparities continue to widen. This is unsustainable. It’s important that the health sector becomes more accessible and efficient. But what are we trying to achieve? If the answer is ‘health’, what exactly do we mean?
The Things That Make Us Feel Healthy
The health sector defines health as the absence of disease. Health and disease are primarily understood through biological measures, with the prevention, treatment and management of disease provided by professionals. Yet when people talk about feeling healthy they include things like safety, relationships, financial security and being able to do what matters most to them.
Beyond Cross Sector Collaboration
The health sector recognizes these things, conceptualizing them as the ‘social determinants of health’. But while asking other sectors to contribute to a health agenda, it can fail to appreciate that those other sectors have their own priorities, seen through their own lenses. The other lens that needs to be given more consideration is that of people and communities.
Acquiring a Sense of Control
Risk factors can’t fully explain why people are healthy or sick. The missing link is whether people have a sense of control over their lives. Yet many are not experiencing this essential part of their health. To acquire a sense of control people must rediscover their agency - their ability to make purposeful choices. Fostering agency is key to sustainably improving health in communities.
The Principles That Describe The Field
Through our work, including the Creating Health Collaborative, we have described 12 principles for how the health sector can adopt ways of working that foster community agency.
- 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
These principles, and the work they're based on, are described in our March 2017 report, Fostering Agency to Improve Health. Our hope is that by gleaning, listing and explaining these principles we’re able to help those in health looking to better include and respond to communities. Implicit to this work is the need to foster community agency.
Only True Commitment Will Yield Sustainability
Our experience tells us that change only sustains when it is community-endorsed. This endorsement requires an inclusive and participatory approach that derives, implements and evaluates solutions collectively. Working this way builds community agency, helping to sustainably improve health.
To embrace this field of practice the health sector must adopt, and adapt to, a more inclusive and participatory approach than it has been used to. While no two communities are the same, the above principles will require investing in process, true partnerships and commitment.
Investing in Process
There needs to be a sustainable process for deriving, implementing and evaluating solutions together. Its success depends on mutual respect for each other’s knowledge and perspectives, mutual empathy for each other’s day-to-day realities and a willingness to find ways to work within each other’s frameworks for accountability.
The process should be implemented through collaborative partnerships that include the health sector, other sectors that seek to work with health and community leaders, including residents. It should also include those already working in ways that foster community agency, such as those in community organizing.
All partners must be committed to developing deeper, more collaborative relationships than may have existed before. And they must be able to commit to the time and resources required to embrace the principles for operating in this field. All sectors, community leaders and residents have important roles to play as well as benefits to accrue.