Community Participation and Mobilisation in CTC (Special Supplement 2)

By Saul Guerrero & Tanya Khara (Valid International)

Over the last few years of CTC development, the process of community participation and mobilisation has become central to the search for more efficient and more sustainable strategies to manage malnutrition. There have been major positive benefits associated with prioritising community participation including improved coverage, increased speed of uptake and therefore, impact, and increased community ownership over CTC programmes, making them easier to hand over. Importantly, enabling the implementation of more culturally-appropriate interventions through CTC, maximises the positive impacts for local people and minimises the opportunity costs to them.

In the short term, community participation can lead to the joint identification of logistical constraints, sites and target areas, as well as the mutual identification of programme opportunities and threats. In the longer term, community participation in programme activities promotes more sustainable programme design and provides a platform from which the communities can demand similar services from the existing national structures. Experiences to date have demonstrated that pressure from communities and their representatives is a necessary factor in promoting institutional integration and longer term, more sustainable programmes.

Experience acquired over the last few years of CTC implementation has led to a gradual improvement in understanding the role of community participation in:

1. Programme design and planning
2. Programme implementation
3. Hand over to more sustainable, local structures

This improved understanding has helped develop the CTC's public health approach. In particular, it has become clear that a high prioritisation of community integration and exploration of the relationship between implementers and beneficiary communities, is vital to programme success. Improvements in programme design, based on these findings, has allowed CTC to reach potential beneficiaries in a more effective, timely and appropriate manner. While the lessons learned are often contextspecific, they highlight the shift in focus from the passive recognition of community mobilisation as important, to actively seeking community integration into programme activities.

1. Programme design and planning

The involvement of existing social, religious, political and economic structures and key figures in the planning stages of the CTC programme can serve as the springboard for community integration into programme activities. By building upon the implementer's knowledge and experience in the area of operation, traditional channels of communication can be utilised to clearly lay out programme objectives and criteria at an early stage and, thus, prevent confusion among potential beneficiaries. Engagement with communities during programme planning can also facilitate the early identification of existing social networks (to be utilised in the mobilisation efforts) as well as the joint identification of sites, target areas, and possible constraints (e.g. logistical, attitudinal, etc.) to the subsequent delivery of services. On the other hand, overlooking community participation during the planning stages is likely to lead to confusion - among implementers and beneficiaries alike - during the subsequent implementation of the programmes. As the examples below describe, the exclusion of communities from the planning stages can significantly hamper the success of programmes, and increase the effort necessary to bring communities on board at later stages of programme implementation.

The Malawi experience

Malawi, where the CTC was originally established as a response to the 2002 nutritional emergency, provides a revealing example of how limited engagement can have important negative ramifications during the implementation of CTC programmes. During the planning stages of the CTC in Malawi, insufficient communication with existing formal structures and the initial omission of more informal or 'traditional' structures and community figures had a substantial impact on initial programme coverage and uptake. The project's limited understanding of local perceptions of the programme delayed recognition of the communities' distrust of unfamiliar Weight for Height (W/H) measurements. This, coupled with an initial failure to inform and involve 'traditional' structures, such as Traditional Authorities (TAs) and Village Headmen, appears to have greatly reduced initial attendance and programme coverage during the first three months of the programme.
If Malawi provided the first lesson on the impact of inadequate participation and delayed engagement with the community, it also offered the opportunity for socio-cultural input to contribute positively to CTC programme activities. In response to the slow uptake of CTC services, the work carried out by sociologists and anthropologists in Malawi offered valuable insight into the perceptions of the beneficiary communities regarding CTC, while simultaneously highlighting some of the shortcomings mentioned above. Changes in programme design and prioritisation based on these findings, in particular the more active and positive involvement of 'traditional' community structures, resulted in a rapid increase in the number of new cases of severe malnutrition admitted into the programme (see figure 7).

2. Programme implementation

The involvement of communities at an early stage - through key figures or otherwise - can often serve as the foundation for continuous active dialogue between the implementers and the beneficiary community. The joint identification of opportunities and threats, as well as the allocation of tasks and responsibilities among all stakeholders, are among some of the areas in which community involvement and consultation have proved invaluable during programme implementation. In South Sudan, for example, joint identification of sites helped to focus on existing logistical barriers to programme uptake. Having noted the difficulties for carers to cross the rivers and swamps during the rainy season, implementers and the local community developed a partnership with local boat-owners, who were recruited and provided with material incentives in return for free ferrying of programme beneficiaries.

This approach to community involvement succeeded insofar as it provided an initial solution to a permanent obstacle. Over time, however, ferry services were disrupted by disheartened boat-owners. The fact that project implementers remained unaware of this highlighted an important lesson: opportunities and constraints at community level are not constant and such arrangements demand systematic follow-up and a forum for discussion and feedback, to remain effective over time. In south Sudan, failure to appreciate this lesson and not institute appropriate mechanisms for discussion and feed-back, led to the weakening and eventual collapse of communication channels post set-up, a discontinuation of the ferry service and as a consequence, decreased attendance, greater opportunity costs to those in the programme and decreased impact.

One of the single most important by-products of developing community participation is the creation of systems for constant dialogue and joint problem solving. There are many challenges to putting such systems in place, but effective systems for communication between implementer and beneficiary provide many benefits. These are essential. On the one hand, regular engagement with the community can lead to the identification of post-implementation obstacles and joint problem solving. On the other, community feedback can shed light on developments at the community level which affect the performance of CTC interventions.

Maintaining such links has required commitment on the part of CTC implementers to understand, but also to bring onboard, beneficiaries' views and needs. In South Sudan, socio-cultural enquiry highlighted the need for an effective solution to the issue of boat-owners and their payment. As a way of facilitating the formulation of a joint strategy, the boat-owners were approached and their input regarding acceptable incentives put forward to the implementing agency. The eventual provision of such material incentives served to re-establish the complementary services for the duration of the programme.

In Ethiopia, consultation with beneficiaries also helped readapt existing programme strategies to better meet the communities' needs. For example, feedback from communities highlighted the difficulties faced by carers crossing rivers during the rainy season. Through further socio-cultural enquiry it was determined that a number of beneficiaries preferred travelling longer distances to crossing rivers, as crossing rivers often required both carers to travel to the sites, thereby greatly increasing the opportunity costs to families. As a result, the programme design was changed, and started to provide assistance in the process of transfer of beneficiaries to the preferred sites, to facilitate programme attendance and uptake. In Ethiopia, beneficiary concerns about contracting diseases at the distribution site, or confusion over the preparation of FAMIX, led to inclusion of these topics in health education and cooking demonstrations at the sites.

3. Hand-over to more sustainable, local structures

Socio-cultural enquiry and the community participation involved has brought together many of the different spectrums of society (i.e. religious, political, social, and spiritual) to discuss and develop more sustainable and appropriate courses of action. This cooperative process has produced recommendations on the preparation of a long-term, volunteer-based strategy for the outreach element of the CTC programme, that are now central to some local CTC strategies. The process has yielded many insights on the acceptability, potential risks and opportunities associated with selecting a community-based volunteer workforce and the need to involve more key figures, in addition to volunteers, to assist in case-finding and referral activities at a community level. The resultant combination of communityelected volunteers with key social figures forms a far more comprehensive and representative outreach network.

For example, in South Wollo, Ethiopia, the initial volunteer strategy struggled. Some village leaders felt they had not been sufficiently involved and therefore didn't support the outreach activities and local level elections resulted in the selection of male volunteers only. Concern addressed these problems by further discussions with village leaders and by going back to talk with communities, advocating for the inclusion of women, stressing their value for the programme in terms of more appropriate/sensitive home visits, and increased understanding of issues of child care. The result was a network of paired volunteers (male and female) working in connection with local leaders who have now been included in all trainings. This has helped to improve the acceptability of the strategy and already, (after volunteers have been working for 3 months), the Concern team and MoH workers are pleased with the referrals being made. As volunteers work within their villages only, their activities, so far, have remained manageable on a voluntary basis.

Lessons Learned

Community volunteers are trained to take over mobilisation and casefinding activities from Concern outreach workers, Ethiopia.

The experience of implementing CTC programmes over the last three years has led to notable improvements in the formulation of a comprehensive but flexible approach to community participation and mobilisation. In particular:

There is no prescribed formula

The level and stages of community participation in CTC programmes must take into account the risks, opportunities and characteristics of each environment. Community engagement must also acknowledge the social potential or 'social capital' of the beneficiary communities, so as to assess the most appropriate areas of community participation in programme activities.

Early engagement with the community is central to the success of CTC

It is important to engage with beneficiary communities during the planning (or even pre-planning) stages of the programme. Early involvement of the community can minimise confusion and increase programme awareness at a community level and facilitate the selection of adequate and sustainable strategies. It can also provide a platform for further, post implementation engagement between implementers and beneficiaries.

There is a vital need for ongoing engagement and feedback

Community mobilisation should be an ongoing process, spanning from the planning stages to (wherever possible) the hand-over to national structures. Communities and their representatives must be provided with a forum for discussion and feedback on issues relating to programme implementation and acceptability. Joint decisions must be followed up to guarantee their effectiveness over time, along with information feedback to communities and their representatives.

Socio-cultural enquiry plays a valuable role in community mobilisation

Socio-cultural input provided during the implementation of CTC programmes has served a dual role. First, it has allowed implementers to gain a more insightful understanding of the beneficiary communities. Secondly it has allowed beneficiaries themselves not only to voice their views on issues relating to programme acceptability, but also to bring about tangible changes in programme strategy.

Large scale community mobilisation is feasible and essential even during nutritional crises

Community mobilisation during nutritional emergencies is feasible. While challenges do exist, experience has shown that the success of community mobilisation depends largely on the level of commitment by the implementer to prioritise community mobilisation prior to, during and after the cessation of programme activities.

New developments and future directions

Volunteers being trained to use MUAC in Ethiopia.

The process of engaging with different aspects of community integration remains ongoing. For example, the role of volunteers within the CTC approach is being simultaneously explored in Ethiopia and Malawi. In Ethiopia, the volunteer system is being introduced as a more sustainable follow-up for outreach activities (e.g. case-finding, referrals and follow-up). Through socio-cultural enquiry, the views and opinions expressed by the beneficiary community have to a large extent guided the selection of volunteers.

Like all aspects of community mobilisation, this level of community integration requires further assessment to guarantee its effectiveness and acceptability over time. In Malawi, this process has been taken a step further. Teams are developing mechanisms to integrate the MoH extension services (Health Surveillance Assistants (HSAs)) with pre-existing, but previously moribund, networks of community growth monitors, with new community volunteers recruited from those familiar with the CTC programme, and with village health committees. Following this approach, outreach activities are supervised by MoH staff but supported by a network of clearly identified community-based volunteers. Future developments in this area include the identification of appropriate incentives for the volunteer workforce, the formulation of sustainable lines of communication between programme implementers and volunteers, and ongoing investigation of the overall acceptability of the approach among the beneficiary population. There is also currently an enquiry into the perceived needs of PLWHA and the current Home-based Care service provision in Malawi, with a view to better identifying the role of CTC in the area.

There are plans to conduct further research in areas where community structures have been disrupted. Based on past experiences, it is felt that the variety and flexibility of the social and cultural links that exist at all social levels mean that even in highly disrupted communities, engagement, mobilisation and participation should be possible. Ultimately, such scenarios are likely to present unique challenges. To engage with whatever aspects of community are present will require context specific responses, albeit drawing upon accumulated knowledge. The task is now to investigate how this can be best done.