the need for community empowerment in a tired healthcare system
The current landscape
Living in the UK, I am extremely privileged to have grown up without the fear of not being able to access healthcare. Our NHS is something that is integral to British culture, founded post-war after a collapse of society, the NHS was a saving grace. However, in today’s global climate of late-stage capitalism, Brexit and the post-pandemic climate our NHS is facing a shortage of resources, staff burnout and declining public perceptions.
Last year, I studied a Master’s in Public Health (MPH). My interest in Public Health arose from my own experiences growing up as a working-class queer person of colour; I was introduced to socioeconomic determinants of health before education. Therefore, I felt passionate about reducing health inequalities and improving policy to benefit the most marginalised groups. However, studying an MPH also highlighted how broken our health system is. Preventative care seems like an obvious way of working – preventing disease in the first instance would reduce strain and costs to the system but also requires the time and effort to implement, which we do not have. The way that our system works at the moment is relatively reactive. The symptoms are treated before the root issues and specialist care is difficult to obtain. With a system that is often chasing its tail, how can we take a step back and improve the health of the population without a complete system upheaval?
A different approach
There are a number of health promotion projects that have been delivered in countries considered 'developing'. These projects were situated in the context of a lack of healthcare infrastructure and of political unrest which forced healthcare solutions to be rooted in community empowerment, promoting self-sufficiency. These projects were innovative, cost-effective and centred the needs of the community at their heart. This article will explore how fostering more approaches like this could help to reduce the burden of disease and reduce the need for primary and tertiary healthcare interventions.
As chronic diseases are posing a greater threat to populations than infectious disease globally, we must look more to self-management and salutogenic approaches. While community empowerment and ‘bottom-up’ methods are nothing new, my experience of working for third-sector organisations has highlighted that their work is often not appreciated enough. This can be demonstrated by the funding landscape for community-led organisations who often struggle for funding despite the vital work that they do for their communities. The COVID-19 pandemic highlighted the importance of community – with third sector organisations and volunteers providing invaluable support to vulnerable members of their communities who would otherwise have been left isolated and in need. Volunteering schemes were even adopted by the NHS during the height of the pandemic to support the increased demand for care. This time was important to demonstrate the impact that community cohesion and empowerment can have during crises worldwide. Governments must therefore invest more into grass roots organisations to improve population health and health service capacity globally.
Too often policy and investment are focused on particular outcomes, which drive funding outputs and public service attention. Personal conversations I have had with third-sector organisation managers speak of how these can be a huge hinderance to their work as they try to respond to their local community needs over policy recommendations. Furthermore, they spoke of the impact of their work can be undermined as they do not have the resources to produce rigorous scientific-style reports. We must learn to trust those working directly with communities in need and place greater value on their voices.
Examples of positive approaches
Across the globe we can find successful examples of ‘bottom-up’ public health programs that have improved community health without the need for primary care interventions.
A classic example of how a community-led approach led to better outcomes is the community-directed treatment method fostered by the African Program for Onchocerciasis Control (APOC), established in 1995. This program was tasked with organising mass drug administration across countries and within rural remote areas. They adopted community-directed treatment to give responsibility to communities to distribute the medication themselves. This program was a major success as it resulted in a high percentage of therapeutic coverage, even in contexts of civil conflict and in remote areas of the rainforest with no transport links, as well as reducing the burden on healthcare systems.
Examples from the UK include social prescribing initiatives which involve primary care providers referring individuals to local, non-clinical services, for example community cooking clubs, walking groups and volunteering. Research suggests that well-implemented social prescribing programs can reduce the demand for GP consultations and A&E appointments in certain contexts. Place-based public health approaches are another community-focused method to improve health and wellbeing. This involves working with local communities to assess their specific needs and collaboratively create and implement solutions. Due to health disparities that occur within countries, place-based approaches also help to reduce national inequalities.
Where trust in healthcare providers is low, or when stigma around certain health issues is present, community health champions can be more beneficial than traditional healthcare providers. One example of this is the ‘Atmiyata’ (meaning shared compassion) program in Maharashtra, India, where local volunteers were trained to be in-community supporters for those suffering with poor mental health and to educate their communities about mental health issues. The program follows a holistic approach to mental health care by centring psychosocial approaches over medical interventions. Altogether Better is a UK-wide program that also mobilises members of the community as ‘health champions’ to collaborate with healthcare providers to provide new solutions and support people accessing services. Evidence from their program evaluation shows that patients’ involvement in the activities led by health champions resulted in increased wellbeing and the capability to live well with chronic conditions, as well as increased awareness on how to access relevant healthcare services.
These few examples demonstrate how communities can be supported to have autonomy over their own health and wellbeing, and how individuals can be mobilised to support healthcare interventions to reduce the need for primary and tertiary intervention.
The future of healthcare
This is not to suggest that primary care services are no longer required, but that we create more resilient communities and equip people with the resources that they need to have more control over their own health, and be less reliant on the system. Although not a radical suggestion, it is one that is still being met with some resistance. Globally, we can benefit from more community empowerment and the strengthening of local networks. Officials need to let go of control and redistribute power to allow for the reimagination of our own healthcare futures.