3: Participatory processes and social power in health are more likely to flourish when grounded within community settings
Interactions with community-level activism and processes appear to be more likely to overcome inhibiting power imbalances when service and others interact within community settings and processes, such as schools, markets, workplaces, sports grounds and traditional gatherings including funerals. This centres processes on the community rather than the services. These familiar and more accessible local processes include ’safe spaces’ for discriminated or vulnerable groups.
Empowerment approaches to food poverty in NE Scotland
In Aberdeen City, falling oil prices slowed growth and increased unemployment and food poverty after 2014. Despite Scotland’s commitment the Sustainable Food Cities approach, use of food banks increased, due to a mix of factors, including increased living costs and precarious employment; changes in benefit entitlements and barriers in claiming welfare benefits. The government is also committed to community involvement in local planning, passing in 2015 the Community Empowerment (Scotland) Act, to support communities to engage in how public budgets are spent.
Aberdeen City Council (ACC) and National Health Service (NHS) Grampian; and two social enterprises, Social Bite and Community Food Initiatives North East (CFINE) have engaged with communities in addressing food poverty, through enabling pathways to employment, financial capability and housing, by supporting households to move out of food poverty and through community grant-making in low-income urban areas through participatory budgeting.
Social Bite is a social enterprise that provides food to homeless people and, through this, pathways to supported employment, financial capability and housing. Sandwich shops and cafés serve the public and customers are able to ‘pay forward’ for meals for homeless people when they buy their own food. The café also provides a social space where people in various stages of homelessness can come in for a sit-down meal in ‘social suppers’, where they also find counselling, skills building and one-to-one support for housing and healthcare. Social Bite also helps with accommodation, training, qualifications, work experience and ultimately a full-time paying job for some homeless people, co-operating with a local organisation, Business in the Community, to organise placements in cafés, hospitality groups and retail outlets. The social suppers and other activities are peer and volunteer led or supported, providing a ‘pipeline of support’ to overcome disadvantage. Their social media presence has also provided a voice for the homeless community and challenged stereotypes, shown in a video of the work (click on the Social Bite. photo adjacent to watch the video)
CFINE contributes to health and regeneration in disadvantaged communities by promoting consumption of healthy food. The organisation co-ordinates the Food Poverty Action Aberdeen Partnership (FPAA), bringing together 61 agencies responding to food poverty. CFINE involves and employs people living with varying forms of poverty and disadvantage, including homelessness, low incomes, unemployment, mental health issues, learning difficulties and offending backgrounds. It runs sixty community food outlets selling affordable fruit and vegetables in deprived communities; distributes fresh, quality and in-date surplus to charities and community organisations and provides a training site and course on cooking skills and healthy eating in a programme supported by NHS Grampian. CFINE is building financial capabilities for people to claim services and benefits and obtain employment; ‘walking beside people who struggle’ to navigate systems seen to be hostile to them.
Recognising these community and voluntary sector assets and roles, and responding to legislative changes in community involvement, the Aberdeen City Council (ACC) initiated participatory budgeting in 2015 to promote inclusive decision-making over the allocation of public funds, including to address food poverty. The first round was introduced in 2015, driven by local champions to allocate £100,000 on youth work and activities for under 12-year olds in five deprived areas of Aberdeen. It was introduced in schools as familiar community spaces, and primary and secondary school pupils voted on the bids produced by community groups, as shown in a video. The bids focused on fitness and health, digital media and technology, citizenship, the environment and the arts. The second round expanded to three urban localities using a web platform UDECIDE, administered by a participatory democracy platform, Participare. Social media was used to widen participation with bids received on digital skills, health, sports and exercise, food suppliers, cooking skills, hygiene and sanitation and community gardens and green spaces. The process concluded with a deliberative forum where voters could interact with bidders. While there is ongoing learning from the process it has enabled creativity and community engagement in decisions on public budgets.
All three processes have benefited from an enabling legal, policy and institutional environment, but also face challenges in cuts in welfare and social funding and weaknesses in co-ordination across services. These experiences show the value of approaches that start in familiar community spaces and empower people to claim rights and benefits, of spaces to innovate, test and develop practices, such as that provided by social enterprises, and of safe spaces and support for people to move out of vulnerable situations and make claims on services.
From the case study report by L D’Ambruoso, P Abbott, F Douglas, E McPherson, E Okpo . Photos: Participatory budget bid: Mini market © The Allotment Market Stall 2016, and Flyer on PB voting event (2nd round), Seaton School Community Project, 2017
Shared evidence and analysis between communities and local government in Quito, Ecuador to mobilise cross sectoral action in health
The Metropolitan District of Quito (DMQ) is the second most populated city in Ecuador. It has grown rapidly in recent decades, with a 2010 population of 2.2 million in 65 districts called parroquias, half of which are urban. While there are social differentials in Quito residents, they have a strong sense of belonging in their neighbourhoods.
A 2016 health diagnosis (Diagnóstico de Salud) observed a high burden of chronic conditions, including in young people. Rather than using a reactive biomedical model to address these problems, a Healthy Municipalities Program in Ecuador is investing in a proactive community-based and population health approach. This applies participatory analysis and action to improve the social determinants of health (SDH) and involves locally elected Comités Locales de Salud (CLS) with community representatives in health situation diagnosis and planning. This approach reflects Ecuador’s 2008 Constitution and legal framework that sets a holistic rights-based approach to social participation in health, linking health to the exercise of rights to water, food, education, culture, social security, healthy environments and other areas that sustain good living (buen vivir).
The Health Department of the Municipality of Quito has since 2016 led implementation of a Healthy Neighbourhoods - closing the gap in health inequality project. It started in Ponceano, Centro Histórico, and Chimbacalle districts, with a combined total of 130 000 people. These districts had poorer health status than others in Quito, but had capacities to support the work. The project integrates health into urban planning, local investment and local public policy, by promoting community-led initiatives.
The health department set up a technical committee of sectors contributing to create conditions health to support intersectoral action; and community health work teams at city and neighbourhood levels to bring local community voice to the processes.
From the side of the city, information on health and SDH is gathered and organised using the WHO Urban Health Equity Assessment and Response Tool, the Centers for Disease Control Healthy Communities program and the Ecuadorean Ministry of Public Health National Program for Healthy Municipalities. This information is used to engage with residents on their priorities in the different neighbourhoods, displaying health data and health determinants by district to make the information publicly accessible, including for informal neighbourhoods.
Residents carry out their own awareness raising and local ‘priority setting’ workshops held within settings in their neighbourhoods. To date neighbourhoods in parroquias Carcelen, Cotocollao, Comité del Pueblo, Chimbacalle, Tumbaco and Centro Historico are participating in the project. They identify their own priorities using participatory methods in these local workshops, and combine this with the evidence presented by DMQ to develop a road map with activities for the priorities in their own neighbourhood, and across neighbourhoods at city level.
The responses are organised in an intervention proposal that is presented to the mayor for approval and implementation. DMQ supports the capacity of residents to generate these intervention plans, or community health plans. As a pilot scheme, DMQ provides incentives such as specialized technical support, access to municipal communication channels (newspaper, radio, social media), and financing for community events to promote community involvement in the development and implementation of the plans. These incentives support community-led initiatives to improve health that benefit the wider community and aim to target and stimulate participation in those with higher health need.
Another approach is the community-led certification of ‘healthy spaces’. These cover fresh food markets, schools and parks within the municipality that meet certain criteria. The criteria are developed by the health department in collaboration with relevant sectors and with higher level health agencies. Municipal workers and community teams assesses food markets, parks, streets, schools and other public spaces and develop workplans for health improvements to address the gaps identified. The participatory action plans are implemented in co-ordination with relevant actors in these settings, with participatory review of how well they worked. The certification process aims to support the administrators and users of spaces like markets and schools to prioritise how best invest limited municipal resources to address those issues that preserve and promote health. It is expected that the initial effort around receiving a certification will forge a working relationship between the relevant actors in the improvement of these spaces, which will continue even after the space meets the criteria for certification. Over time, responsibility for certification of these healthy spaces will be fully delegated to the community health teams.
These processes build on Quito’s recognition of the role, orientation and competencies of the municipality in population health, the culture of collective work for common goals, and a supporting legal and policy framework. This has been critical for engaging other sectors and for the participatory processes to grow. It is a work in progress. However, there is evidence that the participatory processes for information gathering, analysis and priority setting in the community, combined with that collected by the services, together with the team approaches used can encourage co-operation across sectors and with the community to solve problems and to improve healthy public spaces.
These practices do face challenges in ensuring that the mechanisms adequately represent specific groups like youth, women or children. It has been difficult to encourage the work in areas where the culture of participation is weaker, to ensure that private actors, like companies, play their role and to encourage co-ordination across sectors. The expectations amongst community members may exceed the resources that DMQ has for the work. Co-ordination across sectors faces siloes that need to be broken to generate shared planning and action.
Those involved have found that this needs time and ways of building confidence through step by step progress. The information gathered helps to build participation, but can also build this confidence of the sectors and communities involved through the local evidence gathered.
From case study by R Loewenson, F Obando . Photos: Students explaining perceived health problems in their neighbourhoods. Quito © LJ Cárdenas 2016; Community assessing a market, Quito, © J Arevalo, 2018; Steering Committee LJ Jurado 2017