Community engagement for quality

In the context of health systems, community engagement is the process of developing and maintaining relationships that enable stakeholders to work together to address health-related issues and promote well-being, and to achieve positive and sustainable health impact and outcomes.

Community engagement has often been used interchangeably with community empowerment, mobilization, or sensitization, causing some confusion and ambiguity as different stakeholders typically form varying community types. Some important definitions and principles are discussed in this section to provide conceptual clarity and a well-defined scope for community engagement to address the human dimensions of high-quality health care and systems - further information is provided in Community considerations.

Community engagement is relationship-building between stakeholders who integrate their interests across interdependent communities – from service users, government programmes, health service providers, to policy-makers, researchers and donors – to achieve shared health goals that are meaningful to both local populations and health systems. Community engagement is also concerned with how power and authority are addressed to support mechanisms and processes through which shared goals can be negotiated and achieved among stakeholders.

At its worst, community engagement has the potential to burden some communities with the unintended consequences of consultation fatigue, stress, financial and time loss, and disappointment when health services fail to respond or address their needs. At its best, community engagement can strengthen transparency and accountability between all key stakeholders, but this requires discarding linear cause-and-effect approaches and embracing how to work in complex adaptive systems. Work on quality of care always requires awareness that health systems, services and programmes are made up of people and are inherently interlinked.

There have traditionally been two perspectives when assessing the quality of health systems: 1) measures related to disease-specific health processes and outcomes; and 2) measures that account for patient, family and community experience or satisfaction with the health service(s). Consequently, health programmes and services have developed engagement interventions and tools to improve uptake of health interventions by various population profiles. But further work is required in developing these tools and approaches to best meet the needs of communities and health workers. Beyond assessment of quality, engagement of patients, families and communities is also increasingly recognized as a key component of the planning and delivery of quality health services, necessitating attention by actors across the system to build capacity and support for effective engagement.

WHO is currently collaborating with pathfinder countries to fill evidence gaps at the health service and systems levels, and is drawing upon systems thinking in order to fill those gaps. The foundational premise is that in a given system, existing or naturally developed (i.e. organic) relationships already function in which every interaction is an active intervention and communication. Consequently, the focus for understanding of community engagement needs to shift from understanding “community” as a geographical or static group to understanding the notion of “community” as how the connections between and within groups of people function, interact and comprise the sense of community. This approaches community engagement as a process of relationship building that underpins health care planning and delivery. In this way, the patterns of interaction and the nature of linkages within a health system are of equal importance to direct engagement with health service users, their families and health care stakeholders. Trust continually emerges from these relational connections between people and needs to be monitored and attended to across all levels of a health system and over time.