From Health Communication Insights of the Health Communication Partnership based at Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs, this 44-page document describes three U.S. Agency for International Development (USAID)-funded programmes that used community empowering approaches to achieve public health impact at scale in three different settings - Africa, Asia, and the Middle East. It also identifies the success factors common to all three programmes.


It suggests the following 14 points for successful scale-up:

1. Envisioning the scale from the outset;
2. Running carefully chosen pilots;
3. Aim for high impact;
4. Develop solid partnerships with effective organisations at various levels from local to international;
5. Involve partners from various sectors;
6. Foster local leadership;
7. Strengthen systems and organisational capacity as the scale increases;
8. Promote horizontal networking;
9. Test the approach;
10. Consolidate, define, and refine to identify the essential empowering programme components needed to achieve impact;
11. Document with guides and tools;
12. Continuously monitor and evaluate;
13. Recognise achievement and publicise programme results; and
14. Diversify the funding base and encourage community ownership.

The first case study is based in the Philippines, where Save the Children used an approach known as Appreciative Community Mobilisation (ACM) - combining community mobilisation (CM) capacity building and appreciative inquiry (AI), a process of building on an organisation’s strengths - to go to scale to effect change in family planning, child survival, and environmental conservation. Beginning initially in health services, the project began with the strategy that positioning family planning as a contributor to child survival would increase demand for both family planning and child health services. The lowest 30-percent income bracket in communities was the focus. The project evolved into the "People and Environment Co-Existence Development" project (PESCO-Dev), which linked population growth, family planning, and environmental concerns, linking to partners in the environmental conservation sector. The 4-D cycle - Discover, Dream, Design, and Delivery - by which communities created a framework to organise themselves, explore health issues, and then plan, implement, monitor, and evaluate their own projects, ensured participation from the outset of planning and gave marginalised groups the role of advocates for child health and family planning services. The use and enhancement of social and inter-organisational networks fostered leadership within communities, leading to further training and mentoring in conflict resolution, group management, proposal development, human and financial resource mobilisation, and advocacy. Guides were developed to build volunteer training capacity. Mass media campaigning added power to the community-based approaches. Community-to-community exchanges fostered strategy sharing, and the addition of a fifth "D" Dancing and Drumming allowed for celebrations of success.

The second case study, Arab Women Speak Out (AWSO) - designed by CCP in collaboration with the Center of Arab Women for Training and Research (CAWTR), with support from the United States (US) Agency for International Development (USAID) - seeks to empower women throughout the Arab world to achieve their potential inside as well as outside the home. "A central component of AWSO is a series of video profiles of Arab women who overcame gender barriers and reached self-determined goals. Grassroots organisations helped identify the women portrayed in the video to ensure that their profiles were diverse, real, and could translate across borders." They were made with five countries as the focus, but implementation spread to ten countries. these ten 20-minute videos in Arabic are accompanied by a publication: Profiles of Self-Empowerment"; a training manual comprised of eight modules, "Training for Self-Empowerment", a 60-minute composite video that includes highlights from the 10 video portraits (with English sub-titles): a tool for the critical analysis of images of women in the media; and a 15-minute advocacy video (in English). This range of complementary materials was designed to give facilitators choice and flexibility in guiding their sessions. Non-governmental organisations (NGOs) and government ministries implemented the field training of facilitators, and additional off-shoot projects, such as "Women Empowerment for Reproductive Health” grew from the initial series. The project was adapted for the African context as "African Transformation", designed to help participants envision envisions "a tolerant society in which men and women mutually respect each other, critically examine and change gender-based inequities, and participate in equitable decision-making and resource allocation." Strategies of empowerment include "Social Learning Theory," in which "people learn new behaviours and identify their own strengths by seeing those capabilities modeled by others"; "Empowerment Education" that contends that knowledge and action emerge not from experts but from group dialogue at the grassroots level; and recognition of the strong links between a woman’s individual capacities, her connection to other women, and her health.

The third case examined here is the Madagascar Child Survival and Reproductive Health Program. The Madagascar Ministry of Health with USAID implemented BASICS II, an integrated health programme from 1992 to 2002 with the support of several partners, including the Linkages Project, Jereo Salama Isika, Advance Africa, the United Nations Children’s Fund (UNICEF), and The World Bank. This case study focuses specifically on how the project’s community and communication components led to community-based work on a large scale. Briefly, the project aimed to raise levels of vaccination, child health and nutrition, and family planning, all intending to promote a package of achievable goals - reaching 80% vaccination for infants under 12 months, achieving 65% use of child health cards for those less than three years, or completing ten family planning promotion sessions. Communities could choose a goal that responded to their particular need. "By establishing a starting point and a finish line with do-able activities, communities witnessed results and were motivated to sustain active participation and augment their efforts." Achievement was celebrated by, for example: Children completing their vaccinations before their first birthday received a vaccination diploma that families proudly displayed. When 80% of the community received a diploma, the programme would help organise a festival to celebrate the community’s successful vaccination rate. Responsibility and decision making was given to existing community organisations that chose whether to participate, who would receive training, how they would oversee the work of trainees and attract new members, and whether they would extend outreach through home visits. Some successful communities, “Champion Communities”, moved to a higher level of organisation, often with local animators and community leaders as the driving force. Organisational networks involving partnering groups from the education or women's group networks help move the project to scale. A success factor in the Madagascar project was the counselling card, which helped communities ensure message consistency throughout the project. A toolkit that included community tools, advocacy tools, and IEC materials enhanced access to quality health services.

The document lists the following six principles for streamlining community-based programmes:

1. Use simple, action-based messages focused on small, do-able actions that clearly benefit the community.
2. Develop inexpensive, easy-to-use tools. The teams in these examples identified three basic tools for frontline workers - the family health card, the women’s health card, and the youth passport.
3. Focus on skill-based training before transmission of knowledge: "devote at least 50% of the time to practical exercises [to be] carried out by the participants."
4. Recruit many volunteers and hand them ownership: The Madagascar programme estimated a need to enlist as volunteers one percent of the population it intended to reach (or 2,000 volunteers for a region of 200,000).
5. Use mass media to reinforce the key do-able messages and to sustain interest and enthusiasm.
6. Celebrate achievements, such as giving diplomas and launching festivals. Celebrations re-energise the community, attract interest, and build support

For a paper copy, please email: orders@jhuccp.org [1] or click here [2] for an order form.

Emails from Brandon Howard and Alice Payne Merritt to The Communication Initiative on August 1 2007 and May 6 2009, respectively; and the Health Partnership Publications website [8].