John Scott, Sue Smyllie, Brenda Campbell, Robert Bush 5th National Rural Health Conference. Adelaide, South Australia, 14-17th March 1999 Proceedings

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1 Comparison and Contrast of Two Programs which Aim to Increase Community Capacity and Facilitate Sustainable and Responsive Health Systems in Queensland John Scott, Sue Smyllie, Brenda Campbell, Robert Bush 5th National Rural Health Conference John Scott Adelaide, South Australia, 14-17th March 1999 Proceedings

2 Comparison and Contrast of Two Programs which Aim to Increase Community Capacity and Facilitate Sustainable and Responsive Health Systems in Queensland John Scott, Sue Smyllie, Brenda Campbell, Robert Bush INTRODUCTION Beyond health service provision, better health also requires improvements in recognised health determinants including income, employment, education and lifestyle. These determinants are commonly addressed by a large range of government departments and service organisations. Community wide there is mounting dissatisfaction with institutions that monopolise problem solving and subject the community to an unending stream of unconnected programs (National Rural Public Health Forum, 1997), often on short funding cycles. THEORETICAL BASIS Unfortunately, historically, many attempts to involve communities in government service activities have taken the perspective of the services, rather than that of the community (Powel, 1994 ; Zakus, 1988). The two programs under discussion in this paper, the Community Public Health Planning in Rural and Remote Areas Project and the Sustainable Rural Health Services Program make a strenuous effort to take community participation seriously when addressing health issues in rural Queensland. Philosophically influenced by the synergistic theories of community development and participatory action research (PAR) (Aday,1997; Poole, 1997) the programs are using a variety of methods to implement improvements in health and access to health services, in true partnership with local communities. Increasing the ability of a community to analyse critically national and local situations and to organise themselves for change goes beyond simple consultation and has long been the aim of the community development philosophy (Butler and Cass, 1993). The developmental approach seeks to go further to empower communities to meet their own challenges, improving health outcomes consequentially (Nutbeam, 1996 and O Connor and Parker, 1995). Articulated as community wide problem solving, the approach brings together interacting and overlapping networks which form the raw materials from which increased capacity is built at the local level.

3 PAR is concerned with changing individuals and the culture of groups, institutions and communities to which they belong. Models of PAR which draw on a Freirean approach are directly concerned with the relations of power, affirming the inherent capacities of individuals to analyse their own situations and design their own solutions. (Cornwall and Jewkes, 1995). The requirement and opportunity to engage in documented critical reflection, inherent in PAR processes, extends the community development approach to provide access to gleaned learnings to all involved, across a variety of settings. This approach facilitates the development of a learning community. Although capable of selfgeneration, learning communities often require the presence of a community development professional in the early stages. This professional s role is to develop the ability of the community to plan for itself in the long term (Luther, 1994). Full community participation in planning is a result of a complex process which needs to overcome psychological, cultural and cost barriers. The role of an 'outsider' in building community capacity requires an appreciation of these barriers, an empathetic knowledge of the community, its history and norms and a reliance on mutual respect. Rather than just 'doing things for the community' or 'to the community', the belief in the inherent capabilities of the community and individuals becomes of paramount importance (Baker and Teaser-Polk, 1998). Finally, local coalitions which develop to enhance a community s capacity to address public health determinants do not exist in isolation. These capacities are inevitably influenced by the broader political, economic and social environment, transmitted via the links between social structures and the supportive capacities of individuals within them ( Pilisuk and Minkler, 1985). When natural helping networks are disrupted by resource deprivation, the programs which depend upon them are placed within the longest of 'hoeable' rows. METHODOLOGY: COMMUNITY PUBLIC HEALTH IN RURAL AND REMOTE AREAS PROJECT Communities in rural and remote regions of Queensland, identified on population health indicators as having poor health status and being disadvantaged in a variety of ways, who indicate interest, will be invited to pilot a program to address health determinants in their area. Participant communities will have access to funds to address community identified need. An individual tripartite agreement will be developed within each community to address: the identification of an appropriate community based auspicing organisation as depository for the funding; the relationship between the auspicing organisation and Public Health Services; and the relationship between the auspicing organisation and the community regarding the latter s access to funds.

4 These agreements will be based upon a set of values which recognise the community and Queensland Health as equal partners within the initiative. There will be individual core business but a shared goal that can be addressed collectively. Within each community, tripartite policy development will require input from reputational and positional community leaders, other community members and groups and Queensland Health representatives. The program will be facilitated by zonal project coordinators, based in appropriate rural centres, with sufficient infrastructure to support their activities. The role of the project coordinator is as a facilitator and catalyst, assisting communities to define their agendas, to develop plans of action and their implementation, to address identified need. Consecutively, the coordinator will broker the negotiations to implement and resource changes in community or government organisations, which will sustain community program necessities, by strengthening existing friendly community and service infrastructure. The coordinator has a role in assisting in the development of groups or coalitions to promote the inclusion of marginalised groups or communities where no existing networks or advocates exist. The coordinator will also facilitate the bi-directional transfer of relevant knowledge, to assist the community to identify and access support as required, and agencies to respond appropriately. As communities build capacity by implementing projects, the critical reflection necessary within the PAR process will enable the continual redevelopment of the action plans based on identified community learnings. As the program emphasis is on health determinants, collaboration with a comprehensive range of stakeholders will be developed at all organisational and community levels. This emphasis also increases the ability of the program to be meaningfully community driven, allowing strategies which address traditionally 'non-core' health issues such as employment, education, transport and housing to be integrated into the program. The program management structure reflects the expected depth of community involvement and includes representatives of Local Government, consumers, industry, indigenous organisations, learning institutions, social service and non-government organisations, general practice, and a wide range of government departments including Transport, Housing, Police, Education and Commonwealth and State Health. Support for community activities will be sought across this comprehensive range of existing government and non-government services and programs. Additionally, communities will be able to select from a reactive enabling system, components which they identify as essential to the implementation of the community action plan. The enabling system portfolio may include aspects of consultation, training, information and referral, networking, coalition development, resource development, communication, research and evaluation. As system components are called forward by the community, the emphasis will be on extending and strengthening existing programs, whether such programs reside within government or non-government sectors.

5 Within the context of this project, community capacity will be defined across dimensions which incorporate knowledge about health infrastructure that supports and sustains capacity and problem solving between the key players across the network. Evaluation activities will be integrated into project implementation and will seek, not only to measure changes in community capacity, but to reinforce and resource the action research cycle (plan, act, observe, reflect, plan etc) at all implementation levels. A purpose built interactive, information and referral system will be developed. Building on existing multisectoral infrastructure, the information and referral system will be Internet based. It will connect information sites within a framework of comprehensive community planning, simultaneously allowing interaction between communities. In all aspects, the community is viewed as a partner in the process. All significant policy and protocols will be developed via a partnering process, recognising each partners need for demonstrable benefit from participation. By project completion it is expected that reciprocal relationships between and among public health services, community organisations, communities and other government and non-government organisations, will be developed or strengthened. METHODOLOGY: SUSTAINABLE RURAL HEALTH SYSTEMS PROGRAM National and State rural policies recognise that the structure and nature of rural health services needs to be different to urban services if these services are to meet local health needs and produce positive health gains in the population. Queensland Health has responded to this need by developing Policy Guidelines that put forward Multipurpose Health Services as the preferred model for the delivery of health and aged care and other related services in rural and remote areas. This model enhances opportunities for integration, pooling of funds and a primary health care approach to services delivery. Gaining community and health professional support for the introduction of this model is one of the key concerns of both District Health Service Managers and Corporate Queensland Health staff. Approaches to building in community involvement in the development of local services appear fundamental to successful introduction. This program seeks to ensure the knowledge, skills and abilities of community leaders and health staff are enhanced to this end. The partners developing this program identified the limited level of expertise among managers, health staff and key community members to manage the change process and build sustainable rural health services. Approximately ten staff could be identified at district management and direct service levels as having early experience in this field and who might become leaders in managing change processes. The increasing magnitude of change in rural health services strongly suggests that the pool of expertise among health services staff and community members is too small to give the optimum chance for successfully introducing Multipurpose Health Services (MPHS) and related initiatives.

6 The overall aim of this program is to provide support and development to a partnership of local community people and District Health Services staff to work through the process of evaluating and planning their health services. In the short term it is expected that this will assist in introducing the Multi-purpose Health Services model and in the longer term facilitate the ongoing development of rural health services. The phases of the program include: gaining support from rural District Health Services Managers; learning from practice at pilot sites; building and skilling a network of community members and rural health professionals; maintaining and integrating the knowledge, skills and abilities of the network of local communities; and building into the change process feedback by the application of action learning. Workshops will be held in rural and remote locations where community members will be invited to develop a partnership with the District Health Services staff to develop an MPHS or similar type of local health service which is better able to meet the health needs of the local population. The outcomes expected are: 1. Partnerships will be built between the local District Health Service and community and the process of developing community ownership will be enhanced. This will be evident through enthusiasm for increased local involvement and a stake in the planning, implementing and evaluation of services, increased levels of trust between District Health staff and the community and a belief that local participation leads to clearly visible changes so that services that meet local needs. 2. The local skills base will be enhanced with processes being clearly defined and rapid appraisal community mapping being understood as the basis for identifying health needs, health planning and service implementation. 3. Mechanisms will be in place for ongoing partnership development. It is intended that a range of activities will have taken place in communities prior to commencement of the workshops. Corporate support activities will include assisting District Health staff to understand the process of partnership building with local communities and ensure that structures and planning mechanisms are in place to allow for this. Local support processes will be put in place to assist staff with possible changes in roles and functions, which may arise if changes are made to service operations. One of these processes will be the availability of workshops on primary health care principles and applications developed and run by the Rural

7 Health Training Units. These workshops are intended to raise the knowledge level on primary health care principles and application and will be run in conjunction with the partnership workshops. As leaders in this program, District Health Services Managers will take responsibility for identifying local community representatives and involving them in a local reference group. The facilitators running the workshops will take advice from the reference groups with regard to the readiness of the community to commence this program, the most appropriate processes for engagement of the community, and the current capacity of the community to progress. The local reference group will also be asked to brief the workshop planners about the history of the community, local issues of concern and the profile of the local population. CONCEPT MAP FOR THE PARTNERSHIP DEVELOPMENT WORKSHOPS The workshops will have three phases: 1. Preparing the group for work and enhancing the process of working collaboratively. 2. Process of rapid appraisal community mapping as the basis for community engagement in need determination, health service planning and implementation. 3. Moving into action. The process of development of the workshops has been one, which is consistent with a primary health care approach and involved academics, educationalists, District Health Services staff and local community people who have had involvement with a similar process. Following the workshops, a support network will be developed, linking all of those communities currently undertaking a development process for a Multipurpose Health Service or similar. COMPARISON AND CONTRAST Each program will be based on the theory and principles of public health and advanced primary health care. In this regard both will be working to advance community capacity from within the health system and from without. Divergence in methodology is evidenced by: Policy: the Community Public Health Planning in Rural and Remote Areas project (CPHPRRA) will develop policy directions guided by a partnership principle with articulated equity drivers. The Multipurpose Health Services Program policy, as influenced by external factors (such as funder requirements) has been set and will facilitate future development and site selection via problem solving within the context of guidelines;

8 Site selection: 5 th NATIONAL RURAL HEALTH CONFERENCE the Multi-Purpose Health Service Program is based on planning which has been undertaken to guide site selection and their progression to new models. The CPHPRRA project site selection will be significantly influenced by early negotiations with communities; Fundholding: Fundholding and management rests with Queensland Health for the MPHS program; however, the CPHRRA project allows for a community to hold and manage certain funds related to public health. Influences: The essence of the CPHPRRA project is that of a model under development which will evolve within an agreed set of values and principles. The MPHS program is endeavouring to create a fit between the principles and practices of primary health care in an already established environment. Work practices: There are inherent differences related to the actual work that will result from the planning processes. The MPHS is to a large extent about doing the work of providing health services and reforming them in a way which meets the needs of communities. The CPHPRRA project is about community led planning and the implementation of those plans in a way which will facilitate a sustainable increase in community capacity to address any issues which affect them. CONCLUSION As the two programs are evaluated, success factors in each methodology will be highlighted. The comparison of such factors, as relevant to individual outcomes for both programs, will provide significant new contextual information for policy development within rural health. REFERENCES Aday, L., A., Vulnerable populations: a community-oriented perspective. Family and Community Health, 19(4):1-18. Baker, E., A., and Teaser-Polk, C., Measuring community capacity: where do we go from here? Health Education and Behaviour, 25(3): Butler, P., and Cass, S., (eds) Case studies of community development in health. Centre for Innovation in Health. Victorian Printing Pty Ltd:Blackburn. Cornwall, A., and Jewkes, R., What is participatory research? Soc. Sci. Med, 41(12): Luther, J., The learning community survival and sustainability on the plains. International Conference on Issues Affecting Rural Communities, July. The National Rural Public Health Forum, Forum Overview: National Rural Health Alliance.

9 Nutbeam, Health Outcomes and health promotion- defining success in health promotion. Health Promotion Journal of Australia, 6(2): pp 61. O Connor, M., L., and Parker, E., Community health promotion in Health Promotion, Allen and Unwin: Sydney. Pilisuk, M., and Minkler, M., Supportive ties: a political economy perspective. Health Educ. 12(1): Poole, D., L., Building community capacity to promote social and public health: Challenges for universities. Health and Social Work, 22(3):163. Powell, T., J., (ed) Understanding the self help organisation frameworks and findings. Sage: London. Zakus, J., D., Resource dependency and community participation in health care. Soc. Sci Med. 46:4-5,

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