Public Health recognizes the community as an important component in the prevention and control of diseases in the population. However, the current focus of the public health curriculum and practice is more towards the supply side of intervention rather on community engagement and demand generation. Thus, there is a need to emphasize the role of community in public health and define and develop a specific branch or sub-branch as ‘community public health’ within ‘public health’ which clearly defines its aim, goals, and scope. This would not only help in developing a community public health (CPH) approach within public health, but also assist in realizing the importance of people’s participation at the grassroots level. It is envisaged that the CPH approach will fill this gap to achieve ‘Health for All’. (Image: http://www.fundacionfocus.com)
Introduction
The community is subsumed within public health and it is often assumed that ‘public health’ includes ‘community public health’. Nevertheless, it is pertinent to understand and define these terms and their intended meanings. Available literature defines public health as “the science and art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts that will ensure to every individual in the community a standard of living adequate for the maintenance of health” (Winslow, 1920). The Institute of Medicine (1988) defined Public health as “an organized community effort to address the public interest in health by applying scientific and technical Knowledge to prevent disease and promote health”.
The definition highlights that public health is a discipline, which covers everything related to health of an individual, community and population groups [including the animals]. The contemporary public health emphasizes a community-based approach to health promotion and disease prevention. The evidence shows that despite the emphasis, community involvement, partnership, and ownership is lacking in public health programmes and are leading cause behind the modest impact. Interestingly, the focus of public health has always been on population groups, subgroups, and communities. However, there exists no specific branch or sub-branch as community public health which clearly defines its aim, goals, and scope. Thus, it is important to understand and define the term ‘community public health’ and its meaning and scope and how it is different from public health being a sub-discipline of public health.
Definition of Community Public Health
Community Public Health (CPH) can be defined as “a sub-discipline of public health which primarily focuses on community actions in health promotion and disease prevention for common good”. This definition proposed by the authors emphasizes that the core of CPH should be on community involvement and action. The definition subsumes and emphasizes to respect community's understanding of health, particularly their understanding of social, structural, physical environmental determinants and inequities. Community active participation, involvement, and ownership in designing the public health programmes at the local level, its implementation, and actions is the only path to ensure the success of sustainable public health action and better public health outcomes. Thus, empowering the communities for community health action is must which is currently missing in public health discourse and education. One can argue that public health [service/action/program] focus is on empowering the community through the community health workers (CHWs) programs. And to fulfill this role, many times, CHWs were selected from the communities to which they are serving, with a hope that the community will be empowered through them. But we often miss that these CHWs after their induction become a part of the health delivery system or a program and start looking at themselves as a health service provider and community as a receiver.
Community empowerment and involvement
In such a scenario, an articulation of the basic tenets of the sub-discipline which can visualize and materialize the public health programs effectively and also serve as a vehicle to address the aspirations and apprehensions of the community is required. What is needed is a vision which connects, enable and empower the village institution and local bodies such as Gram Sabha [1] or Panchayat [2], to improve the health and wellbeing of people and communities. The CPH approach advocates to focus on the community as a whole represented by their local bodies or through some other mechanism, which is accountable to the community. The mechanism, strategies, and tools for community empowerment and action is core to CPH approach, which should include a dimension of deliberately involving the community in health decision-making. For example, primary health care structures managed by community-selected and supported health committees such as Village Health and Sanitation Committee (VHSC). The community should be on the forefront as guardian and the primary actor in preserving and ensuring the health of its members is a key framework for community health programs.
It has been observed that efforts without involving communities have not delivered sustainable long-term gains (Smarte, 2010) in health. Therefore, it is imperative to focus on the people-centric approach of community empowerment to improve and sustain the health gains, particularly in resource-constrained settings. The government has started recognizing this and has incorporated a community role in their health policies and programs, but in practice, the priority has been on the supply side of the health system and little attention on demand generation, community involvement, and empowerment. For example, in the National Health Mission Program of the government of India, the emphasis is on decentralization, community involvement, and ownership. However, despite the efforts through Accredited Social Health Activists [3] (ASHA), health system delivery and healthcare focus are still very much on provider based curative health care services rather than on demand generation and community involvement. Although some interventions are having an influence at the community level in improving maternal and child health or HIV/AIDS, the focus of, most of these interventions are not on sustaining the gains through community empowerment and community actions but primarily on delivery through a weak and overburdened health system. For example, immunization programs help in improving child health by reducing infant mortality, however, the onus of program delivery is on health workers or health system rather than on the community. Involving community members, a village health and sanitation committee (VHSC) member, and community health worker (CHW) using mobile or internet technology and social media could be an opportunity to co-produce innovative health promotion solutions. In the past, mobilizing and educating communities and empowering them for action has always been an issue because of a lack of community participation, concern, and apathy, and because of the amount of effort and support needed to address these gaps.
Building community competencies and leadership
It is imperative that the focus of CPH should be on building community competencies for community-based public health practice and research with a focus on identifying the role of cultural, social, and behavioral factors in determining the delivery of community-based public health; linking social, environmental and cultural causes of disease. It should focus on empowering and educating community leaders, key stakeholders, and other members to define, assess, and understand the health status of the community, determinants of health and illness, and factors contributing to health promotion and disease prevention, and factors influencing the use of health services affecting communities. Besides, this understanding of the community structure, interactions, and its dynamics are equally important to build the communities’ organizational, leadership and managerial skills to achieve the desired results by bringing household, communities and health systems together. Recognizing that the leadership ability of community and its leaders are of utmost importance for better linkages between community and health services and in increasing the demand of health services at grass root level, which will empower communities to take action in health promotion and disease prevention for the common good by connecting, capacitating and empowering village institution and local bodies such as Gram Sabha or Panchayat, to improve the health and wellbeing of people, communities, and common masses.
Conclusion
The authors believe that CPH approach will help the community and its leaders in mobilizing communities and engaging them in a collaborative mode and have multiple opportunities for input and participation for community mobilization for community health. This would not only help communities to gain a sense of ownership over the initiatives, but also assist them in realizing the importance of people’s participation at the grassroots level. Although widely recognized, there are very few instances of community being bestowed with such opportunities. It is envisaged that the CPH approach will fill this gap and create new opportunity to ‘Achieve Health for All’. The most innovative aspect of this approach is the volume of ideas/concepts generated by the community and its leaders based on micro-planning developed in consultation with the community on issues specific to their health needs.
Notes
1. Gram Sabha: Gram Sabha [in India] is a permanent body consisting of all the adults (above 18 years) members of a village.
2. Panchayat: Gram Panchayat [in India] is a local body at Panchayat level whose members are elected by the people for the term of 5 years. One Panchayat may consist of 2-5 villages.
3. ASHA: Accredited Social Health Activist (ASHA) is a community health worker under the National Rural Health Mission (NRHM) program of the Government of India.
References
Institute of Medicine. (1988). The future of Public Health. Washington, DC: National Academies Press. Pp. 7.
Smarte. (2010). Community Involvement. Sustainable Management Approaches and Revitalization Tools – electronic. Available on http://www.smarte.org/smarte/dynamic/resource/sn-community.xml.pdf (Accessed on 28 November 2015).
Winslow, C. E. A. (1920). The Untilled Fields of Public Health. New York, NU: Health Service, New York County Chapter of the American Redcross. Pp. 34.
Authors:
Dr. Anant Kumar (pandeyanant@hotmail.com)
Associate Professor at the Xavier Institute of Social Service, Ranchi, Jharkhand (anantkumar.in)
Prof. Kesavan Rajasekharan Nayar (krnayar@gmail.com)
Professor & Director at Global Institute of Public Health, Thiruvananthapuram, Kerala.
