Institutionalising community engagement for quality of care: moving beyond the rhetoric

Community engagement is essential for quality improvement

Although specific evidence is scarce and often imprecisely described, community engagement directly supports quality of care.14 Benefits include better health outcomes,615 more equitable delivery of services,16 and enhanced community empowerment, ownership, and accountability.1718 In part, this is because community engagement ensures that interventions are specific to their context, as communities have input into identifying needs and delivery systems.19 A 2015 qualitative study in the Democratic Republic of the Congo, for example, found that using community scorecards as a form of community engagement improved key elements of quality of care, including access to services, relationships between communities and providers, and service provision.20 With respect to equitable service delivery, a 2023 mixed methods study examined knowledge, attitudes, and practices of Indigenous Mayan women in Guatemala (who are often marginalised) over three years of community engagement in a combined care group package, which sees communities identifying priorities and developing action plans along with the implementation of care groups and community birthing centres. It found significantly increased rates of participation in decision making and reported qualitative improvements in empowerment.21 Additional evidence indicates that community engagement can help make healthcare provision more people centred, by identifying and appropriately responding to community needs, for example.5 Community engagement can facilitate relationship building between communities and providers,14 which can encourage a positive experience for women in pregnancy and childbirth.22 A 2020 study from Ethiopia on women who regularly attended antenatal care but did not choose to give birth in a facility identified negative experiences with health providers as a driving factor.23 Community engagement can also support monitoring14 and can hold providers, policy makers, and community actors accountable for services and healthcare provision.2425 On the basis of this evidence, and recognising the ways in which community engagement is integral to quality improvement processes,26 tools13 and modules27 have been developed to support policy makers and implementers to integrate community engagement in quality of care improvement efforts.

Unicef has proposed quality standards and indicators for community engagement across four categories (core community engagement standards, standards supporting implementation, standards supporting coordination and integration, and standards supporting resource mobilisation).28 These include criteria around meaningful participation and its processes, policies, and approaches, and around how action plans and identification leaders and mobilisers should be developed with communities. The Network for Improving Quality of Care for Maternal, Newborn, and Child Health has recognised community engagement as core to quality improvement initiatives,29 and efforts to strengthen the institutionalisation of community engagement across its countries are ongoing.

Enthusiasm and advocacy for community engagement to drive quality improvement in maternal, newborn, and child health are abundant globally and nationally,29 but more robust documentation of community engagement processes, programmatic monitoring, and outcome reporting is needed,30 especially because concepts can be difficult to evaluate and compare.31

Community engagement can differ across and within programmes, and there is a risk that, without a clear understanding of what community engagement is and how to support its integration within policies and programming, poorly designed or superficial attempts at community engagement could result in less coordinated interaction between community actors and health service delivery counterparts. Institutionalisation of community engagement would mean having formal policy and implementation plans and structures supported by leadership and resources across various levels of service implementation—for example, establishing structures that see active community representation and representatives supported across the entire health system at the community, regional, and national levels. Financing and support for such work would be built into policies and frequently monitored. This, with robust reporting, evaluation, and accountability mechanisms in place, such as scorecards, published indices, or transparent and published expenditures, would ensure evidence based and sustained integration. Experience from Ghana and Nepal show how efforts to document the effects of community engagement on quality of care can embed it in national health service delivery planning.

Community generated evidence in Ghana

A comprehensive national community engagement strategy can help institutionalise this critical component of quality improvement. Community engagement has been the bedrock of Ghana’s agenda towards universal health coverage, helping bridge gaps in healthcare access.32 The Community Based Health Planning Services (CHPS) for delivering primary care in Ghana was implemented because up to 70% of people lived more than 8 km away from a healthcare facility. Within CHPS, community health management committees (CHMCs) were formed to mobilise resources for facilities, support community health volunteers, strengthen the health system, and empower communities. Situated at the community level throughout the country, they are composed of people selected by community leaders and endorsed by community members and are associated with a specific facility. Because communities were engaged in establishing and scaling up the CHMCs, and because CHMCs are integrated in Ghana’s primary care through CHPS,33 the CHMCs have enhanced community involvement and ownership of primary healthcare.34 The National Quality Healthcare Strategy evolved as a result of learning from CHPS and broader community engagement and puts clients’ experiences at the centre of quality healthcare.35

During implementation of CHPS, a community scorecard was introduced for the community to provide formal feedback on quality of care in maternal, newborn, and child health to all healthcare levels. Every quarter, CHMC members engage with the wider community to discuss, score, plan, and monitor the health facility using predetermined quality of care indicators related to both provision and experience of care, including indicators such as waiting times, medical support availability, and provision of respectful and compassionate care. Scorecard results are entered into an online platform, which can be visualised for each facility, regions, and countrywide for decision making. After each scorecard assessment, health facility leaders and CHMCs develop a joint action plan to fill the gaps observed, and community representatives lead action plans for quality improvement in health facilities. Thus, in Ghana, community generated evidence showing improvements in quality of care has deepened community ownership of healthcare and continues to drive progress. The role of community engagement in the scorecards has been seen to elicit further support from policy makers and health officials in a positive feedback cycle that solidifies the role and importance of community engagement such that it becomes institutionalised.

Community voices therefore have a critical role in shaping healthcare policy.

Community led solutions in Nepal

In the early 1960s, the recently democratised government in Nepal began focusing on selected health programmes to support community development. Over time, efforts to mobilise community health providers led to engagement initiatives, such as community level health promotion, and governance and social accountability activities including the female community health volunteer programme, mothers’ groups, and health facility operation management committees, which work collaboratively with communities to improve health. When found to be effective, these were scaled up, leading to increased access across the country to quality health services, especially for maternal, newborn, and child health and family planning programmes.36 Community engagement through health facility and operational management committees, for example, led to several positive changes in quality of care including improved skilled birth attendance and child growth monitoring.37 The gradually expanded and tested community engagement initiatives drove community led solutions to overcome barriers to quality of care in maternal, newborn, and child health.

Community engagement activities such as mothers’ groups and health facility and operational management committees expanded the reach and enhanced social accountability for marginalised and rural groups.38 They have improved health outcomes and have proved cost effective.3940 A 2020 systematic review of cost effectiveness of women’s group interventions found that, although staff costs represent about 77% of the total spending for these groups, scaling up to all rural regions in Nepal would cost 6.3% of total governmental health expenditure but would avert 15% of total neonatal deaths.41 The success of these community led solutions42 has solidified their role as core components of the community health system43; the cost effectiveness and promotion of equity facilitated government support of these community led solutions. Institutionalisation of community engagement is reflected in Nepal’s national health policies and strategies (1990, 2014, and 2019), which recognise community engagement as an established pillar of primary healthcare.

Moving beyond rhetoric

Experiences with community engagement in Ghana and Nepal show the importance of regular evaluation and rigorous documentation to be fed into iterative policy making for solidifying the role of community engagement in health programming. Assessing both the cost effectiveness of community engagement activities and their effects on health equity can also support institutionalisation. It is important to recognise that institutionalising community engagement is not a quick process—it takes time and sustained investment. Other strategies to support the institutionalisation of community engagement can include recruiting community stakeholders, such as leaders or champions, from the onset of developing health initiatives44; using feedback mechanisms to inform and refine implementation45; and employing multiple coordinated initiatives targeted at a common goal but tackling different system levels or actors. Despite the importance of generating evidence to support and institutionalise community engagement, it continues to be poorly described and documented in the literature, and claims about the importance of community engagement are often not substantiated by evidence.37 Understanding how, why, when, and for whom community engagement for quality of care can work is essential. Using common definitions and, when appropriate, standard indicators can support cross context learning and provide clarity to the field.

Ghana and Nepal are positive examples, but community engagement is often not a simple, linear, or straightforward process. In both countries, early official support of community engagement, an ability to make results of community engagement efforts visible to policy makers, and the governments’ readiness to adopt and adapt policies based on evidence of impact were critical. There are barriers to the institutionalisation of community engagement. Healthcare workers, including community health workers, who frequently operationalise community engagement activities are often over-worked, under-resourced, and unequally distributed across contexts.46 Institutionalisation efforts might therefore add additional work burden to community health workers, and failing to consider or manage their capacity could hinder efforts to institutionalise community engagement. Lastly, community engagement is neither easy nor cheap and requires a great deal of technical competency and resources. It is a dynamic and demanding process that needs appropriate support; but the pay-offs in health and society can be immense when done correctly. To provide people centred, high quality care that is responsive to the needs and contexts of communities, we must move beyond community engagement as rhetoric and re-focus on actions that support its institutionalisation.