The ACQUIRE Project

This 12-page working paper presents a conceptual framework for analysing community engagement in reproductive health (RH)/family planning (FP), and the role the community plays in institutionalising lasting behaviour and social change. It is based on a review of documents, best practices, and the lessons learned from the ACQUIRE Project (which stands for Access, Quality, and Use in Reproductive Health), a 5-year global initiative initiated in 2003 with support from the United States (US) Agency for International Development (USAID) and management by EngenderHealth in partnership with the Adventist Development and Relief Agency International (ADRA), CARE, IntraHealth International, Inc., Meridian Group International, Inc., and the Society for Women and AIDS in Africa (SWAA).

The Active Community Engagement (ACE) Continuum that is outlined here can be used by global RH/FP projects for strategic integration of community engagement into service delivery and to build a shared understanding of community engagement when designing, implementing, and documenting programmes. The framework provides a basis for discussion related to indicators, time frames, and definitions of terms and is a tool that global RH/FP projects can use to build a shared understanding of community engagement when designing, implementing, and documenting programmes.

The document opens with an exploration of the meaning and importance of community engagement, which involves sharing information through media campaigns, representative leaders, or civil society and local community groups. The concept is that, when communities receive correct information, they are empowered to take appropriate action, which generally leads to long-lasting, positive health outcomes. The ACQUIRE Project learned that there are multiple levels of community engagement, and that meeting the needs of all stakeholders requires flexibility by everyone involved, to respond to changes in community needs, political crises, shifts in funding, or other unpredictable changes.

To assist with these and other challenges, the ACQUIRE Project developed a supply-demand-advocacy (SDA) approach which is illustrated as a model on page 3 of the document. Community engagement is one component of the SDA approach, and it is a critical aspect of a rights-based perspective on access to RH/FP information and services which acknowledges that political, economic, and cultural structures can be barriers to the public's ability to participate meaningfully in the solutions to their RH/FP health needs. The ACQUIRE project has found that, as communities and their members become more engaged, they can assume new and collective roles in decision making around allocating resources, planning programmes, defining policies, and ensuring their right to quality services.

To lay the groundwork for an exploration of how this collaborative process could be shaped, the document next offers 8 principles as a guide for RH/FP service-delivery projects when integrating community engagement into programme strategies:

• Value partnerships, and their unique contributions, from the global to the community levels.
• Be clear about the purposes and goals of community engagement before starting.
• Define from the beginning such terms as participation, communication, engagement, mobilisation, and empowerment as they apply to the project.
• Understand that flexibility (of donors, organisations, and communities) is needed to collaborate and share power at all levels of community engagement.
• Be willing to determine the level of engagement, including key capacity-building interventions and the time frame, before starting a project.
• Agree on clear indicators with expected outcomes and on a documentation process that will reflect both RH/FP outcomes and levels of engagement.
• Expect to engage and then re-engage throughout the life of the project, as communities are dynamic and behaviour change is not linear.
• Plan the time frame and budget for maintaining community involvement from the start of the project.

The continuum itself consists of 3 levels of engagement - which move from consultative to cooperative to collaborative - spanning across 5 characteristics of engagement, which can be adapted as needed but which generally include:

1. Community involvement in assessment - At the first level, general community meetings are used as a means of consulting community members to refine project design. At Level 2, in addition to such meetings, focus groups can be held to understand more about the communities' perceptions about RH/FP services and related issues. At Level 3, additional participatory approaches can be added that facilitate the identification of social and cultural barriers to accessing RH/FP services.
2. Access to information - At Level 1, communities are engaged only as recipients of information, with the emphasis on the sharing of accurate RH/FP information with the community at large. At Level 2, the communities are included in the dissemination plan for the information. For example, peer educators may be chosen from the community and trained to deliver messages and to facilitate community discussion groups. At Level 3, a process may be initiated by a local partner organisation wherein engagement is used to move from the passive reception of information to a dialogue that involves all groups (including the marginalised) to address the multiple social and cultural barriers that hinder the sharing and receiving of information.
3. Inclusion in decision making - Influential community leaders are sometimes treated as proxies for the community at Level 1 of the continuum. At Level 2, mechanisms such as advisory groups are developed, or existing groups are supported. By Level 3, civil society groups are included and involved in decision making related to RH/FP programming.
4. Local organisational capacity - At Level 1, capacity building is focused on the health service system. At Level 2, advisory groups' skills are supported so they can oversee the quality of services and facility management, with community engagement processes including facilitated communication processes to allow communities to engage in dialogue and debate about RH/FP issues. At this point, "[i]nvolving civil society collectively (versus individually) through community networks and organizations is important if communities are to respond effectively to identified community problems..." By Level 3, external organisations help build the capacity of groups to advocate effectively for RH/FP programmes and are committed to engaging the community in roles that can affect policy and social change.
5. Accountability of institutions to the public - Level 1 is a centralised approach that does not encourage community involvement. By Level 2, there are advisory groups that can interact with government agencies, and by Level 3, input from the community about resource allocation is highly valued.

Page 10 of the document lists a number of lessons learned from ACQUIRE's experience with community engagement. In essence, "[t]he ACQUIRE Project learned that communities can be engaged through a variety of interventions. The more engaged we were in building the capacity of the community to be equal partners, the more empowered communities became. Champions emerged who influenced both individual behavior and social change, resulting in mutual accountability between government and communities for RH/FP services and policies." With regard to this notion of champions, in particular, the authors stress the importance of identifying community, provider, government, or other champions, publicly promoting them, and supporting their efforts through appropriate public support.

In conclusion, ACQUIRE's experience has shown that "community engagement is not a one-time event, but rather is a process that...becomes less vertical, with communication based on dialogue rather than messages. The more horizontal the process is, the more the community is empowered to own the process...Although it is the health outcome that is of most interest to RH/FP programs, there is evidence that empowerment relates to health outcomes. Therefore, community engagement is important to consider in planning and evaluating programs."

ACQUIRE website.