W(h)ither community
Around the world, community-based approaches to promote better health and development using information and communication technologies, particularly those concerned with facilitating health and development literacy and social and behaviour change, face significant challenges. Access to resources, e.g. skills and funds, is but one of those obstacles; deeper, more fundamental challenges also persist.
A good example of an ICT-enabled health programme resulting from a community-based approach is Phukusi la Moyo (Bag of Life). It centres on a 30-minute weekly radio show, which is heard and discussed by more than 3,000 women in some 250 village-level health groups in Mchinji District of Malawi. The focus is on safe motherhood. The most interesting thing about Phukusi la Moyo is how it was conceived and designed and how it continues to be managed. The idea for a mass communication programme emerged from an action-reflection process driven by the groups themselves. Representatives of the women's groups worked on equal terms with health experts to develop the programme's key messages and outcome objectives. These in turn were illustrated through actual life experiences, and are actively updated through on-going month-to-month oversight and coordination.
Community-based approaches, such as the one underlying Phukusi la Moyo, work from the inside out. They are firmly embedded in the communities they aim to serve. The community is simultaneously the focus of change and a primary actor in identifying issues and strategies to address it. The equitable participation of local citizens and groups aims to make development efforts more relevant and effective by ensuring that the people most concerned are in dialogue with the ones facilitating those efforts and in many cases, providing outside expertise and support.
Community-based approaches that enable active participation are especially important when the issues and problems at hand are contextually and socially determined and when the solutions have less to do with predetermined right solutions and information and more to do with answers that draw on local knowledge and culture, that is, those that emerge from dialogical processes between and among different stakeholders. As a case in point, the safe motherhood solutions featured in Phukusi la Moyo are simple and limited in number. In this instance, not just the message information is important but also the way decisions are made about those messages and how they are presented and understood.
A community-based approach is not the same as extending services to a local level (though clearly local access to services is important). Nor is it to say that community-based approaches should be isolated or divorced from national policies and programmes; quite the opposite. If we are to avoid the risk that a community approach becomes a way for state authorities to offload public responsibilities, it is essential that community efforts function within a larger environment that both enables and values these unique characteristics and contributions.
Although recognition of the importance of community as an element of development initiatives may have increased recently in some circles, e.g. academia, the opportunities to put community-based approaches into action, individually or at scale, are still scarce and at times it feels as though we are going in the wrong direction.
Why?
The first mile is still the last mile
Focusing sustained attention on community-based ICT efforts is a long-standing problem in the intersecting worlds of national and international development wherein decisions are centralized in capital cities.
The paradigm shift proposed in the late 1990s by Moetsabi, Paisley and Richardson with respect to connectivity - essentially a call to reconceptualise and reprioritise the last mile as the first - is widely relevant and as important in the context of educational and developmental programmes, e.g. concerning health and livelihoods promotion, as it is in relation to connectivity. Although such a shift may (or may not) be taking root in some sectors and regions, it has yet to bear fruit on a large scale.
What makes a community approach work so well at the local level is also what works against it at national and international levels. Just as national development initiatives are by nature external to local jurisdictions, community-based efforts and organisations that manage these generally fly below the national and international radar; as such they often fail to register on the screens of central policymakers and planners.
Few sites fly more below the radar than the eight village-ICT centres of the Solomon Islands' Isabel Province. Santa Isabel is an island with a population of some 30,000 people and as many as eight distinct languages, not including English and Solomon Pijin. The centres feature two-way radios, email facilities and low-watt FM transmitters. When they are functioning. the centres create content and facilitate information and communication exchanges in local languages in ways that make sense to local people. The network is, in many respects, a model for participatory communication about health and development in a region of unique linguistic diversity and a myriad of social challenges. In 2009, based on a four-day programme development workshop, local health workers paired up with village media operators to design a 13-week radio series about diabetes, youth reproductive health, waste management and sanitation, which was then produced and broadcast, drawing in local theatre groups and folk musicians in the process.
Regrettably the ICT centres are also an unfortunate showcase of the sort of dysfunctionality that results from unsolved tensions between local community and state ownership. When they are not functioning - which sadly is a lot of time - it is generally a result of equipment breakdowns and a dearth of local capacity and resources. Few examples provide a better contrast between first and last mile perspectives. Viewed as last mile outposts, the centres suffer from out-of-sight, out-of-mind neglect and are, at least in the minds of disconnected policymakers, perpetually in need of repair, difficult to manage and obviously unsustainable. On the other hand, seen from a first mile vantage point, the centres offer unique opportunities to do just about anything - from singing songs and telling jokes to raising awareness of provincial development projects and promoting positive parenting.
As the Isabel example illustrates, community efforts are localised and therefore offer limited opportunities for the type of large-scale, big-numbers approaches that drive today's development planning. Community-based information and communication technologies and media tend to prioritise the use of local languages and dialects, which are often not widely spoken (or valued) and certainly not in the corridors of power in capital cities. Likewise, they focus on local contexts and draw on local experts and actors that generally do not resonate beyond their own borders.
The result is that community-based approaches are, as yet, not fully integrated into the mainstream of health, development and education planning. They may be seen as desirable - as they are in Isabel - which is itself a significant step forward; however, we have further to go in changing mindsets regarding which mile comes first.
One practical solution in this regard has been the promotion of networks and networking among community-based groups allowing them to function at different levels, e.g. with a national presence, and also to build capacity as a sector. The vision of these networks could be described as a community of communities, a national complex of local, participatory organisations and or programmes.
Community participation is difficult, expensive and troublesome
Shut up and listen! is the title of an insightful Ted Talk by Ernesto Sirolli in which he suggests that "what you do [to provide better aid] is you shut up. You never arrive in a community with any ideas." It is a provocative way of sharing an important principle, essentially that we must grow development solutions from scratch; that prescriptive and predetermined efforts, no matter how well-intentioned, will not succeed because they will be neither relevant to nor sustained by the people that matter. Sirolli's is a proposition that clearly echoes Freirian principles of adult education and participatory development and communication, penetrating to the heart of the participatory approach. Change emerges from a conversation between different stakeholders; however it is a dialogue that must start with decision-making by the people most concerned with what the conversation is about and one that will allow its resolution to emerge from the process.
This is not easy to do. Real participation requires a balancing act between internal and external interests. It demands a range of methods to consult and converse equitably with as broad a cross-section of the community as possible throughout the development process. Communities are far from homogeneous and participation in public life, particularly involvement in decision-making is fraught with larger issues relating to access and power. For these and other reasons, participatory and community-based approaches can also be expensive, requiring a substantial investment of resources, both human and financial. The dysfunctionality of the Isabel Province's ICT centre network is a testament to how good ideas falter because of insufficient consultation and a fearful unwillingness to put the last mile first in the budgeting process.
Participation is also troublesome. It involves seeking out and acting on people's feedback, which might just include exhortations like Sirolli's to shut up and listen. There is little doubt that it is faster, easier and simpler to lay down programmes from a central point than to grow them organically from local contexts. Current practices, e.g. in health promotion, are often deeply entrenched, making change difficult and at times undesirable for those with vested interests in the status quo. Mchinji District, the site of the Phukusi la Moyo maternal and child health programme, saw three different District Health Officers in as many years, making practical, systemic changes to health promotion budgeting difficult to achieve, efforts that were further complicated by the practice of employing local health officials in traditional, top-down approaches.
In contrast to Sirolli's advice concerning the best way to approach development, i.e. shut up and listen, when the opportunity arises to discuss development and promote the critical importance of integrating community as a strategy, we need to stand up and speak out, perhaps even yell a bit, in order to share experience, propose collaboration and offer tools and practical assistance.
Proof in the pudding, not the publication
Community-based approaches are frequently slow, erratic and even messy, at least by comparison with the sort of results-based approach to development that now dominates at the international level. Community initiatives may have emerged as an ad hoc response to a problem or represent some sort of compromise or a hybrid of internal and external efforts. Chances are community-based approaches are less focused on products and more on processes and that the lines between outputs and outcomes are blurry or broken.
To some degree community-based approaches do not lend themselves easily or naturally to evaluation and therefore clear and objective evidence may not be readily available. It is still more likely that a community-based organisation or initiative's proof of success will be in the pudding, so to speak, than in a highly structure piece of research or a published evaluation. Perhaps the best evidence that a community approach and the programmes or services that it delivers are working successfully is that they are still there, still in operation. In Mchinji, faced with the end of external funding for the Phukusi la Moyo programme, the women's groups started to pitch in their own funds to keep the programme alive. Their contributions represent a small percentage of the programme costs; but are an indisputable demonstration of the value of the programme and send a strong message to the District Health Office that promised but failed to take on the programme as part of their responsibility for community health.
Practitioners do realise that mere survival, local testimonials and even demonstrations of love may not offer sufficiently convincing evidence for external decision-makers to make serious commitments nor provide local organisations and actors with adequate tools to use in improving their work.
What is interesting is that the drive for better monitoring and evaluation is increasingly coming from community-based organisations, activists and professionals themselves based on the realization that they need to provide better evidence, be more accountable and continually improve their services based on more rigorous observation and analysis. Combined with the efforts of researchers and monitoring and evaluation specialists, there is room for considerable optimism that the type of evidence required to convince external stakeholders of the value and importance of community-based approaches will become easier to achieve.
Let's hope so.