Community Health Expert's Meeting, June 14, 2017

Dr. Carissa F. Etienne, Director of PAHO

Let me begin by saying good morning, and welcoming you to this meeting on Community Health. I am very happy to see people from across the Organization and from various programs and levels of the Organization. Most importantly, we have the experts.

Let me also express my appreciation to those who organized this meeting that brings together such wide experiences at various facets of community health. Today, I have more questions than answers, and I choose to be provocative today. I do not expect to provide you with any answers. I expect to provide you with my own experience of 41 years working in the community and public health arena. , and I have seen all of the movements and all of the changes from Alma Ata to SDG's now. I have seen them from the perspective as a national professional in my own country, from a regional office, and from the global level. That is what I can bring the most and share to this meeting. It is against this background, of us having to rethink what is community health and what is really the concept definition of community health in the 21st century; in the era of unfinished MDGs, SDG agenda, Universal Health Coverage, Universal Access to Health, and Access to Social Determinants of Health including Primary Health Care Approaches. Is the construct that we once had of community health still appropriate today in its original form? or is it evolving and requires that we rethink how we approach it?

As I said, I have more questions than answers, and I choose to be provocative because I want you to keep asking yourself questions as we go through these three days. I want to invite you to keep an open mind and to re-examine the disciplines, concepts, definitions, and relevance in this era of the 21st Century. To be truly open, will require you to rethink and to pay attention to the evolving nature of community, community health, and community health approaches; and these three do not have the same meaning or definition.

I want to provide you with a little history. I want to begin from Alma Ata to SDGs. The Declaration of Alma Ata was very clear, that people and communities would have to be at the center. It was very clear about community participation and community empowerment. It was also clear, if not stated categorically, but implied that communities were geographically determined and it assumed a certain level of homogeneity of neighborhoods. We were involved in the mapping of those communities, in house numbering, and enumeration of the inhabitants by household; that was a basis for the organization and increasing access to care and allowed us to be able to reach those who were not reached. Health systems engaged healthcare workers, sometimes called community healthcare workers (CHWs), to actually go out into the community, and not only to sick individuals, but also to bring about that level of community health education. We saw village health committees being created and this was an important organism for community empowerment and community engagement. In certain instances, they became the health educators of those communities. You would engage in training for trainers and they would use Community Health Expert's Meeting, June 14, 2017 different methods to educate the rest of the communities, but they were also, in a way, representing a semi-political force in their decisions around health where they were correctly implemented.

In the early 80s, many of those community movements toward empowerment targeted many rural and poor communities. It was only after time that we would see different approaches involving urban dwellers in more development countries. As we began to experience those rural communities, we saw that they were really neighbors- they talked to each other, shared schools, shared common problems, churches, festivals, etc. So they were truly a community with similar norms and values and were based around shared experiences that were built over time. In that era, community was adequately defined within a geographic construct. Now we have health promotion. I witnessed the movement from where it was merely health education to the movement towards health promotion. Health promotion became a science and a discipline, but also health promotion approaches. We had great difficulty in defining and separating the two. The health promotion as a discipline of science and a study from the health promotion approaches that should be utilized within communities to bring about community health.

We saw that the empowering of communities began to evolve from mainly geographic districts/villages to settings. So, we went to work in healthy school, cities, work places, etc. This was still geographic, but they were defining a community in different ways for health promotion action. As we move from the various Declarations surrounding health promotions, we went from Ottawa, Jakarta, Beijing, to the 6th and 7th WHO Global Health Promotion Conferences, we began to see a lack of definition between health promotions as a science and public health. I think the scientific community was not honest enough with the governments that we worked with. We did not say that public health encompasses health promotion and includes community health. So, what we saw happening is that some countries would say: I am doing health promotion not primary health care, and these were some things that were happening inadvertently. We felt responsible for it because we fed our countries primary health care- some of them persisted and then the language changed. We then fed them local health systems, the silos approach. Then some countries it was not the primary health care that we thought about in 1978, it became the UNICEF version-selected primary health care. You need to know this history because what you do in the next three days is guided by that history. We saw the evolution of health promotion and the evolution of what we think is community health.

In 2006 in the Region of the Americas, we created a working group, chaired by Barbara Starfield, which consisted of many experts across the countries to rethink the renewal of primary health care. Because at that time we had more than 20 years of Alma Ata, we needed to talk about the new concepts that have no commentary on the whole primary health care arena. The document that was produced was short and because there was such a demand, PAHO distributed more than 40,000 copies. This document, for the first time, clearly distinguished the first level of care from the primary health care approach and clearly showed how communities were involved. Community Health Expert's Meeting, June 14, 2017

In 2014, our Member States framed the Resolution on Universal Health Coverage and Universal Access to Health and Access to Social Determinants of Health. I am glad they did this because globally, universal health coverage has become the overarching and driving concept. But it is very often misunderstood as universal health coverage only meaning financing and financing mechanisms and it forgets the whole notion of strengthening health systems based on primary health care which preceded this entire talk on universal health coverage. All Member States said they were not only interested in individual health, but also interested in the public health component and how people can be mobilized to be at the very center.

Strengthening of health systems requires looking at the building blocks, but very importantly with people and community at the center. If we are honest with each other, we have not given this area sufficient thought- people and communities at the very center. When I was in WHO as Assistant Director General for Health Systems and Services , I tried to revitalize a piece of work on community participation and social mobilization and it did not take sufficient structure because this is an area where we say we do it, but we are not very good at it. Our Member States wanted the concept of essential public health functions. They wanted it clearly articulated and they wanted the concept to include prevention, promotion, and social determinants of health.

When we talk about health systems based on primary health care, the old problems seem to continue. Are we talking about first level of care or are we talking about the primary health care approach that embodies other approaches that we speak about that includes community, community engagements, and the utilization of community health approaches. As PAHO, we need to also admit and to do selfcriticism because up until now, the work that we are doing on universal access to health and universal health coverage sounds as if we are only talking about individual access to care. Our emphasis is on individual access to care. Our Member States wanted us to look at the public health aspect of care and the communities as proponents of their own health. In a way, we have not been able to sufficiently clarify this or include it in the work and programs we are doing. This is an opportunity for us to do that. How to link public health and how to link community health with health systems strengthening based on primary health care, SDGs, Leave No One Behind- it is important for us to do this. When you talk about ‘Leaving No One Behind', for us in health it means health for all. If you recall, the Alma Ata Declaration was predicated on the values of equity, solidarity, and human rights. It is the same thing we are hearing again which means we have not sufficiently dealt with this and that this is an area we need to work on.

I ask you. How do you appropriately and adequately define Community today? If you look in the literature, there is not much agreement. Some people in the literature say it has to be geographic location or settings. A quote from David McQueen, a health promotion guru, states "A group of people with diverse characteristics who are linked by social ties, share common perspectives and engage in joint Community Health Expert's Meeting, June 14, 2017 actions in geographic locations or settings." How have people seen themselves as community these days? We must move on from geographic description and we need to think about the different settings. We talk about church, work, school, indigenous communities, etc. Importantly, we cannot forget to mention two very important communities that have totally re-defined what a community is. Those are the HIV/AIDS and the LGBTQ communities. If it wasn't for the HIV/AIDS community, we would not have advanced in HIV treatment. They mobilized within themselves across countries and Regions to ensure their group was organized. This way they could define their needs of their own community. They empowered themselves to educate each other to ensure access to medication. Because of this example, we cannot just stick to geographic descriptions. Today, a geographic location could be virtual and communities that can be built on social networks. These communities empower each other and seek to influence decisionmakers. I believe to limit our definition of community by geographic dimensions in the 21st Century is shortsighted and ignores the opportunities provided by these groupings even though they are not bounded by geography. I would like you to take this into consideration.

So, for community health, we are never going to shut down departments of community health in universities. Therefore, we must recognize that there is a discipline and a science of community health that aggregates many sciences to train minds to think differently- statistics, epidemiologists, etc. What is more important for us as an Organization that must work with Member States to address leaving no one behind; the community health approaches become more important and how these are adapted to the realities and needs of a defined group of individuals.

Just as there is little consensus on what constitutes a community, community health is even worse. Also, there needs to be some clarification between the relationship of public health, community health, primary health care, universal access to health, universal health coverage, and SDGs. I believe community health refers to all aspects of health: comprehensive care, social determinants that are relevant to define communities which should be based on shared experiences. The community groups empowered to take responsibility for the diagnosis of their situation, needs definition, and ensure action to address these needs.

Recognizing this, I have important questions for you:

  1. How can we, as an Organization, meaningfully address and take action in this era to implement the concept of people and communities at the center of health systems strengthening?
  2. How can we make the system work for the various communities?
  3. How do we ensure community, social mobilization, and community empowerment for health?
  4. How do we amplify prevention and promotion programs within communities?
  5. How can we ensure a place at the table for communities? What are the tools and approaches for doing that?
  6. How can we help communities as proponents of health actors and not passive recipients? Community Health Expert's Meeting, June 14, 2017
  7. How do we define within PAHO, program of work with national and local governments for truly empowering communities?

To do this, requires rupturing the social and economic exclusion, the arrogance of health professionals and serious attention to the social and environmental determinants and the SDGs. These approaches are critical to leaving no one behind.

Communities today are more culturally diverse, dynamic, more open, multi-ethnic with different priorities, norms, and interests. As a result, the meaning of community has changed and evolved over time while also permanently changing in its different context. Understanding this dynamic and form of diversity will allow us to engage, approach, and recognize communities in the Region of the Americas in a more effective way reaching better those who lack a voice in community structure. So, there are different types of communities that are not only determined by geographic location. Each is unique in its own way and each is held together by some common characteristic- by their vision, goals and needs. How are we going to be able to tease those out and to have them admit what is their own vision, goals, and needs?

I believe we are gathered here today to start a dialogue; a dialogue regarding the definition and scope of community health in the 21st Century. To find new ways in how PAHO should engage with different communities. I do not believe PAHO has engaged in community health for a long time- we have a long way to go. We should be working with Member States to be that proponent for empowering communities and identifying new communities that we must engage in. We have forgotten how to engage with communities. We need new innovative tools to begin to address community health within this era. Life is evolving, and our work has to evolve as well. We have tremendous access to technology that we didn't have in the 80s. The tools are advancing and how have we appropriated all of those in the work we must do to improve community health. I think absolutely there is a need for PAHO to bring clarity on community health approaches and their relationships with primary health care, based health systems, SDGs, universal access to health, and universal health coverage. If we do not do it, we are negating on what our responsibilities are. We have to do it, and now is the opportune time. It must not be the work of a program or department, but it has to be all of PAHO approach- across programs and across levels. We must be the catalyst for that change that needs to occur at a global level. I see it as our responsibility to ensure that this can happen.

I look forward to your recommendations. From the passion I have shown here, I will be looking at it very carefully. From your deliberations and your recommendations, we can begin to move PAHO and our Member States closer to community empowerment that needs to occur so people can also be responsible for their own health.

Thank you and good luck.

Community Health Expert's Meeting: Defining Community Health in the 21st Century
Community Health in the 21st Century