Learning from initiatives on equitable urban health and wellbeing in east and southern Africa
Loewenson R; Mhlanga G; Gotto D; Cjhaikosa S; Goma F; Walyaro C, EQUINET, 2022

An Accelerating City Equity Project led by the International Society for Urban Health aims to build a ‘community of practice’ for healthy urban societies, to exchange knowledge on and contribute to the implementation of those practices found to be most catalytic for equity in cities. Towards this, work was implemented in 2022 in EQUINET to gather evidence on promising practice aimed at addressing urban health equity and wellbeing document in east and southern Africa (ESA to contribute to learning within the ESA region and to share and exchange with other regions in the ACE Project. This report presents the work carried out in the ESA region through a desk review of online documents and case studies from selected cities, of areas of promising practice. It shares insights and learning from the findings on practices that promote urban wellbeing and health equity. Collectively, the initiatives have yielded a range of outcomes and changes. In terms of processes for equity-oriented change in urban wellbeing, the report outlines a mix of interventions and tools that promote both participatory and recognitional equity as pivotal to change. Many of the insights generated relate to the design of initiatives and the efforts made to stimulate cross sectoral, multi-stakeholder inputs as a response to the multi-dimensional nature of the drivers of inequality and deprivation. The report notes, however, that initiatives need to connect beyond the local level if they are to have more impact on the structural dimensions of equity, and points to national level inputs that appear to be important to sustain and support such local level practice.

Making Change Visible: Evaluating Efforts to Advance Social Participation in Health, An Implementer’s Resource
Loewenson R, Simpson S, Dudding R, Obando F, Beznec P, TARSC, Shaping health, 2021

qr-code.pngIf you are responsible for—or engaged or interested in—advancing social/community participation in health in your local area, we developed this resource for you. There are a variety of resources available on how to organise SPH, but there is limited guidance on how to evaluate its effectiveness. This publication fills that gap for those in a position to make decisions or take actions to advance SPH. This resource is thus not about how to implement SPH in your community, but rather how to evaluate your efforts on SPH, to help you answer the question: what differences are our SPH efforts making? The Resource aims to help you and your colleagues to conduct a baseline assessment, creating a critical reference point at the start of your SPH program that will help you plan your work and enable you to track changes as they are achieved. It will guide you in carrying out a performance evaluation, which will tell you how well the SPH intervention is performing as you are implementing it  for you to review and make any 'course corrections' needed. Finally, it explains how to conduct an outcome or impact evaluation, assessing the changes achieved, directly and indirectly, as a result of the SPH intervention. The Resource was developed by an international team co-ordinated by Training and Research Support Centre and with support from supported by the Robert Wood Johnson Foundation Global Ideas Fund at CAF America. We are piloting use of the Resource in 2022, so if you are interested, and would like a copy of the Facilitator Guide for Resource, or other support for its use, or to let us know your feedback on it, please email admin@tarsc.org. 

‘We are subjects, not objects in health’: Communities taking action on COVID-19
Loewenson R; Colvin C; Rome N; Nolan E; Coelho V; Szabzon F; Das S; Aich U; Tiwari P; Khanna R; Gansane Z; Traoré Y; Yao S; Coulibaly S; Asibu W; Chaikosa S, TARSC, 2020

CE%20Fotos%20do%20ato%202.jpegThis document co-ordinated by TARSC in EQUINET and in the Shaping health consortium, and with input from co-authors from nine countries provides evidence of practical and affirmative options of people-centred, participatory forms of community organizing and engagement in diverse areas of prevention, care and wider social protection in responding to COVID-19. The 42 case studies from different regions intend to inspire, inform and support.

The case studies are unique, diverse and rooted in widely different contexts and histories. In all, the people involved are subjects, full of life, with rights, ideas and rich experience. They report the creative development and use of social media platforms for action across all areas of response, connecting people within and across communities and countries, giving voice and visibility to community experiences and linking people to key resources and services. They show the role of an ICT that supports problem solving and expression of marginalized voices. Simple tools, norms and standards, and open data facilitate creative community engagement. The experiences show organization around symptom surveillance, testing, contact tracing and risk mapping, linking people to support and proposing feasible, less harmful ways of organizing risk settings or implementing lockdowns. Community volunteers have produced and distributed PPE and other health technologies; have self-organized medical, care and counselling support; and have organized food and other essentials for those in need, in ways that address psychosocial challenges and cultural and religious beliefs and that overcome stigma and social isolation. The initiatives have linked small scale farmers to household deliveries for food security, provided food through communal gardens, kitchens and ‘people’s’ restaurants and supported access to emergency lodging, benefit schemes and safe water. They demonstrate that a compassionate society enhances public health. While not without challenges and reversals, they are solution-focused and use their actions to negotiate and lever the resources and relationships that they expect from the state. Many build on histories, ideologies, structures, organization and relationships that began long before the pandemic, enabling a relatively rapid response to new challenges posed by COVID-19 and with an intention to sustain relevant innovations after the pandemic. They reach to socio-economically disadvantaged groups within communities, especially where organizing processes were participatory and democratic, strengthening collective organization, investing in capacities and leadership and making links with more powerful groups to address local priorities and negotiate delivery on state obligations. They build new relationships between communities and producers and between communities and health workers, and solidarity interactions with international agencies and diaspora communities. The relationships built show the value of productive capacities, economic and system interactions that were previously ignored. While some are a response to imposed measures insensitive to community realities, in others the state, especially at local level, provided enabling conditions and resources and was responsive to local initiative, especially where state capacities were decentralized or autonomous. In responding to deprivation or deficit, there was a caution not to take over state duties, nor to be dominated by the state, and an observation from service workers that community organization and advocacy is what makes the state move.

The challenges presented by the pandemic are creating demand and space for innovation, and in many settings communities are rising to that demand. The mobilization of affirmative community effort and creativity needs to be recognized in the story of the 2020 pandemic. The authors hope that the case studies inspire the proactive efforts of other organizations and communities. They also carry a consistent message: The response to COVID does not need to generate fear and coercion. It can be inclusive, creative, equitable and participatory. Co-production and co-determination with affected communities are not an optional ‘add-on’ to COVID-19 responses. They are fundamental to a successful response.

Health from whose lens? Shaping health participatory satellite session , Global Symposium for Health Systems Research (HSR2018), Liverpool, UK
Training and Research Support with Centre; Escuela de Salud Publica Chile; Centre for health and development Murska Sobota; Municipality of Quito; PIH Health; Athens City County Health Dept; EquiAct,; University of Aberdeen; RWJF, 2018

This document presents a summary of the discussions at the Shaping Health Consortium satellite session at the 2018 Global Symposium on Health Systems Research in Liverpool UK. It briefly captures the ideas exchanged, and images of the session as a reminder (better than words) of the energy and connections in the room! It presents 

  1. An introduction to the session, and key concepts involved in our Shaping health work on social power in health
  2. Two groups, introducing on country case studies with discussions on issues raised from the case studies and participant experiences on grounding health action and services in community systems: Grounding social power in health in local economies – Slovenia and Ecuador and Building and bridging synergies between formal state mechanisms and informal community processes- Chile
  3. A plenary review and discussion of key themes emerging and feedback from findings from Shaping health work
  4. A fishbowl discussion on adapting approaches and learning across settings and countries, and sharing learning to encourage local practice, with discussant inputs from Athens County Ohio and PHI Health US on their experience, from Robert Wood Johnson Foundation on experience as a funder of global exchanges and from participants.
  5. A final summary of follow up points, resources and links
Evaluating efforts that build social power and participation in health systems: Introduction to the briefs
TARSC;Shaping health

These four briefs (separately shown on this site) provide information on evaluation of social participation and power in health to support capacity and practice. They are intended primarily for those working directly with social participation and power in health systems, but also for managers, funders and others who engage with them. They intend to inform thinking and approaches and provide links to deeper resources and do not intend to prescribe or be a ’how to’ toolkit. The four briefs address:
BRIEF 1: The concepts and approaches applied in ‘monitoring and evaluation processes.
BRIEF 2: Approaches to assessing change in social participation and power in health
BRIEF 3: The methods used for participatory evaluation
BRIEF 4: Engaging funders and formal systems on evaluations of social power in health

BRIEF 1: How do we understand the concepts of ‘monitoring and evaluation’
Loewenson, M Mastoya, F Obando, P Frenz, C Mbwili Muleya, Shaping Health, 2018

In Shaping health we focused on forms of social participation in health where communities co-decide the actions and services that affect their health and wellbeing. Such processes seek to enhance peoples’ collective power and to challenge power relations that lead to social injustice and inequities in health. How do we understand what works in such processes and what learning we can share? How we evaluate efforts that build social power and participation for improved health and health systems is the subject of the four briefs in this series from Shaping health. In this first brief we outline concepts and terms commonly used in discussions on monitoring and evaluation. We indicate what motivates– and discourages - us in evaluating social participation and power in health, and observe how evaluation processes can themselves affect social power. The brief introduces the basic concepts and terms used in evaluation. It has introduced the different types of evaluation carried out at different stages of processes, and the different forms of evaluation. It outlines the incentives and disincentives for implementing evaluation on social participation and power in health. Evaluations on social power in health are themselves affected by the power relations that affect health equity, and thus advocate for participatory, realist and appreciative forms of evaluation that integrate the lived experience and knowledge of those affected and contribute to their social capacities, voice, confidence and power to produce change.

BRIEF 2: Approaches to assessing change in social participation and power in health
Loewenson R, Mastoya M, Obando F;Frenz P; TARSC Shaping health, 2018

In this brief we discuss options for framing and measuring social participation and power in ways that acknowledge this subjective, relational and complex nature of social change processes and of health systems. The brief outlines the challenges in and some options for defining and setting indicators of social participation and power, used in evaluations of interventions. While evaluations often search for quantitative evidence and such data can be used in evaluations of outputs and outcomes on social power, the brief highlights a range of qualitative forms of evidence to obtain a deeper understanding of processes, relationships, outcomes and factors relating to participation and power, in accessible ways for community engagement. The brief points to questions and measures for assessing the processes, practices, capacities, relationships and power relations involved in strengthening social participation and power in health.

BRIEF 3: Methods used for participatory evaluation
Loewenson R, Mastoya M, Obando F, Frenz P; TARSC Shaping health; 2018

In this brief, the third of four, we outline, with links for further information, the methods that can be used in different stages of participatory evaluation of social participation and power in health. This brief outlines the methods and tools used in formative, process and summative / outcome stages of evaluation of social participation and power in health. The brief gives most attention to methods that enable participatory evaluation, that collect evidence in ways that may be more accessible for community engagement and that may be part of an ongoing strategic planning, management, review that is itself sustained and participatory.

BRIEF 4: Engaging funders and formal systems on evaluations of social power in health
Loewenson R; Mastoya M; Beznec P; Frenz P; Mbwili Mueya C; Obando F; TARSC Shaping health, 2018

In Briefs 1 and 2 we described how a theory of change connects evaluation processes to the thinking behind, design, planning and implementation of programmes, as a means for review and learning. Equally, for funders and communities engaging on evaluation, building this mutual appreciation of the different concerns, assets and experience that each brings cannot only be applied at a late stage, in summative evaluations. A more engaged collaboration and dialogue between funders, implementers, the community and those directly involved in programmes calls for all to be involved and in dialogue across the entire process, from planning to evaluating. This brief discusses issues and tensions in and approaches for doing this, for negotiating diverse interests in evaluations; building shared frameworks and managing different expectations of the evidence from evaluations. Addressing the diverse and sometimes divergent expectations of those engaged in some way on evaluating social participation and power in health is, however, not an issue that can be met by tools alone. Community processes and the actions of those seeking to build social participation and power are in essence about identity, values, rights and politics. At its heart discussions on evaluation are about whose story about the situation, initiatives and changes is being told, what and whose learning and capability are being built and shared.

Building social power and participation in local health systems: Learning from practice
Loewenson R with Beznec P; Coelho V; D’Ambruoso L; Dorras J; Dudding R; Frenz P; Gerrity P; Howe D; Ivie V; Matheson D; Mbwili-Muleya C; Mohanty R; Ndetei D; Obando F; Simpson S; Tanzman B; Wagner B, Zapelli R , Shaping health programme, TARSC, 2017

Shaping%20health%20synthesis%20cover.jpgIn 2016/17 the Shaping health project explored how local health systems in different countries have built social power and participation in health, and the challenges they face.

This paper synthesises the experiences and learning across the work in the project to address four questions:  Why build social power and participation in health?  How is social participation in health organised, with what tools and resources?  What insights and principles can we share on enabling social participation and power? and Does social participation make a difference? In Shaping health we focused on those forms of participation where communities co-decide the actions and services for their health and wellbeing, through their awareness, their collective power and power to act. We reports our learning on how this is organised and implemented, with examples of practice from local health systems in diverse countries. As key messages, we share ten principles that appear to be common to practice that builds social power and participation in health and health systems.