Community Health – Where do we go from here?

CCIH 2008 Annual Conference

W. Michael Smith, MAP International

Is this a ‘fullness of time’ moment?

Is God calling CCIH to specific role(s) at this time?

Possibly some sequel to the role of CMC?

Many developments by/affecting Christian agencies

• Religious health institutions provide 40 – 70% of health services in many sub-Saharan African nations

• Major contributors in Primary Health Care movement, Alma Ata (1978) and Peoples Health Assembly (2000)

• Promising models of comprehensive, community-based health development

• Encouraging theological shifts yielding increased energy among evangelically-minded - - spirit of Micah Network

• Broader appreciation & engagement of FBOs (Mark Dybul’s comments)

Encouraging developments in global health:

• World seems more ready than ever to tackle the diseases of poverty

• Foreign policy attention

• Unprecedented billions available for health

• 16% decline in estimated AIDS prevalence since 2006 (UNAIDS 2007)

• Surge of attention to Malaria & other neglected diseases

• 1990 – 2006 under-5 deaths declined from 13 to 10 million (World Bank’s Global Monitoring Report – 2008)

Deeply troubling health conditions:

• In 12 countries in sub-Saharan Africa, under-5 mortality rates have increased, rather than decreased, since 1990. World Bank’s Global Monitoring Report – 2008

• Only 16 of 68 countries where 97% of global under-5 deaths occur are on-track to achieve MDGs (Henry Perry – 5/24/08)

• Globally, over 1100 children die every hour, mostly of preventable diseases and conditions

• Eighteen of the least developed countries, over 460 million, scored lower on Human Development Index in 2003 than in 1990; “an unprecedented reversal” Human Development Report, 2005

• Life expectancy continues to fall – below 50 in some countries

• Environmental and economic factors undermine already fragile systems for survival

• Lack of coordination and a ‘dangerous deficiency in local hospitals, clinics, labs, medical schools and health talent’, makes it likely that ‘much of the cash now flooding the field is leaking away without result.’ (Laurie Garrett, ‘The Challenge of Global health” Foreign Affairs January/February 2007)

• Drain of health workers, e.g. 2000 – 2005, Malawi’s government health system lost 53% of hospital administrators, 64% of nurses, 85% of physicians, mostly to NGOs & international agencies & institutions

• Costly bureaucracy and intervention models in the aid industry

Complicating factors and Compromised Solutions

In the midst of these realities and perceptions, we ask:

Where do we, CCIH, go from here?

Based on this conference, it seems…

The time is right for breakthrough efforts by Christian agencies to demonstrate that: holistic, integrated, community-based approaches to health

development,whose energy for change is self-empowerment, offer hope for sustainable, comprehensive changefor communities in chronic cycles of poverty anddespair.

Holistic

By contrast, “Stove-piped” or vertical interventions

• Often provide intensive funding for important needs, e.g ARVs, malaria

• May leave basic, general health needs unfunded

• 2006 President Clinton hoped HIV/AIDS programs would help all other health initiatives

• Between 2002-2006, successfully provided ARVs to 5,000 needy Haitians - - HIV prevalence dropped from 6 to 3%

• But during same period “Haiti…went backward on every other health indicator.” “The Challenge of Global Health”, Laurie Garrett

HIV & AIDS - Illustrates the Integral Nature of Human Health

• Physically - Ravages of disease, vulnerability• Relationally - Alienation from family, friends,

neighbors• Emotionally - Shame / stigma (two-edged sword)• Economically - Can’t work• Spiritually - Those engaging promiscuity, unfaithfulness

- Those oppressing women & girls - Powerless women & girls - Despair

• Nutritionally - Can’t eat, can’t afford to feed family• Educationally – Children can’t go to school• Environmentally – No resources for preservation• Cyclically/generationally - Children “cursed” for generations

Millennium Development Goals

1. Eradicate extreme poverty and hunger2. Achieve universal primary education3. Promote gender equality and empower women4. Reduce child mortality5. Improve maternal health6. Combat HIV/AIDS, TB, malaria and other

diseases7. Ensure environmental sustainability8. Develop a Global Partnership for Development

9. Refuse culture of violence & unrestrained arms trade

The reality of

Social Determinants of Health

demands

holistic approaches

Community-based

“Solutions are in the communities” – Dr. Jack Bryant 5/24/08

Authentically community – based

Swimming against the current of prevailing paradigm of externally driven interventions

Our language reflects our struggle:“Give power or dignity to communities”

“Community-based” is a belief first:

belief that local communities - especially those who have lived in chronic poverty - have the inherent strengths to author their own stories

- to rediscover their capacity to dream

- to learn to evaluate their situation

- to mobilize & organize the resources

- to take constructive steps to influence their world

- to evaluate and continue improving

Dr. Margaret Chan concluded her address to International

Federation of Red Cross and Red Crescent Societies –Global Health and Care Forum 2008:

“Primary health care starts with people. Our common humanity compels us to respect people’s universal aspiration for a better life. It compels us to respect the resilience and ingenuity of the human spirit, and the great capacity of individuals and communities to solve their own problems.”

If we believe that communities have the inherent strengths to “author their own stories”, then

Communities don’t need us to:• “give them dignity”• “give them power or authority”

They already have it. • Birthright as children of God• Oppressed, stifled, beaten down –

disempowered• We helped teach them “poverty is their

greatest resource”• Together we can be converted to the belief:

- Communities are partners & resources, not targets

“Concept Note” from the Africa Regional Faith-Based Coalition (March 2008) expressed concern about:

“…a dominant culture of service-provision, intervention and welfare is well-intentioned, but undermines the capacity of local communities to acknowledge concerns, and act on shared vision to respond to those behaviors that put them at risk. Technical and organizational capacity development is often valued over Human Capacity Development.

Human Capacity… describes the basic common human strengths for care through accompaniment and participation, change, hope, relational influence, and belonging. These are innate, but often suppressed and need support to be unveiled.”

Empowerment (cont.)

Finding the right language:

• “Self-empowerment” vs. we “empower” others

• Or “agency” - WHO article, February 2006, "What is the evidence on effectiveness of empowerment to improve health?", explained:

“Advocates or external change agents may catalyze actions or help create spaces for people to learn, but sustainability and empowerment occur only as people create their own momentum, gain their own skills, and advocate for their own changes.”

• Whether called agency or self-empowerment – It is the energy for change (Locating the Energy for Change: An Introduction to Appreciative Inquiry, 1999 C. Elliott)

• Sine qua non of sustainable, holistic health development

• Research on definitions and indicators of empowerment – Rollins School of Public Health, Emory & MAP International

Empowerment (cont.)

Five “I”s of Self-Empowerment

• Identity – Healthy spiritual and psychological aspects of self-worth, self-esteem and self-confidence

• Ideas – Ability to envision and dream alternative futures

• Implementation – Capacity to act through effective goal-setting, planning and the appropriate knowledge, skills and tools

• Impact – Learning through monitoring and evaluation

• Influence – Advocating for just and fair laws, policies, systems and structures

MAP International

The time is right for Christian agencies to demonstrate that… (holistic, community based approaches bring greater help)

Evidence-based demonstration• “We do good work. Trust us!” – not good

enough• “It has been difficult for NGOs to demonstrate

the worth and relevance of their work in a manner acceptable to skeptical outsiders.” (Linda Kelly, Patrick Kilby, and Nalini Kasynathan, “Impact Measurement for NGOs: experiences from India and Sri Lanka”, in Development in Practice, Vol. 14, Number 5, August 2004)

• Technical issues: measure impact or human process? Qualitative and quantitative.

• Devise new paradigms & systems of M&E

Major funders more open to FBOs. Ironically:

• Sudden, massive funding could devastate CBPHC

• Feeding frenzy among NGOs

• Counter-productive flow of funds to programs

• Problem: Belief (funders & NGOs) that money is the essential resource, the primary agent of change.

“This is a time to challenge that belief and operate from a totally different perspective. Our view is rooted in the spiritual transformation that renews their capacity to solve their own problems.” Dr. Carl Taylor – 5/24/08

Funding

So our way forward must ask:

If the most-needed resource is communities who have rediscovered and reengaged their capacity to dream and to author their own story,

what mechanisms, processes, criteria are needed to find and invest resources in ways that enhance rather poison that most-needed resource?

Confidently ChristianWellspring of self-empowerment –

• Self-respect & mutual respect from deep encounter with God’s love gives birth to hope.

• Spirit of Life in Christ Jesus = “energy for change”

• Relentless in our ministry with the poor – “Unconditional love” – Paul Freeman

• There is such an “inextricable link between health and social justice” that Dr. William Foege, has said that “public health is the secular arm of theology”. (Deborah McFarland, Rollins School of Public Health, Emory University, “Clanging Symbols”)

Engage churches as partners in new vision of “…thy will be done on earth as in heaven.”

Instead of traditional, dualistic view (church deals with spiritual matters, others deal with physical needs), rediscover the gospel of the Kingdom of God.

You know it is a Christian congregation because:

• Blind receive their sight

• Lame walk

• Lepers are cleansed

• Poor have good news preached to them

Christian congregation as outpost and agent of the comprehensive shalom which is the presence of the Kingdom• Lawndale Community Church

Echoes of Moses…

This is the time…

• To go beyond the “low-hanging fruit” (Dr. Carl Taylor, 5/24/08)

• For a “radical break” (Dr. Carl Taylor, 5/24/08)

• “We have a great opportunity for new thought about global health. The faith community as a whole can begin to take leadership that we have not taken.”

So, to our question

Only that day dawns for which we are awake

Henry David Thoreau