Community engagement is not always easy. How can we ensure there is legitimate representation? Whose voices will be heard? How will marginalized groups participate in the policy processes? In this blog I reflect on a few possible methods to engage citizens during the implementation of the Sustainable Development Goals (SDGs). 

In my previous piece I shared my views on why it is important to engage citizens in health research, development projects and policy processes. But, surely there are challenges of adequate and legitimate representation of citizens, both in national and global policy processes. For example, how do we ensure inclusion of women living furthest from administrative centers? Experience from various contexts shows that there can be different paths leading to inclusive decision-making and empowerment. I suggest three here, before highlighting several ways in which donors could reimagine how they enable conditions for community engagement and health for all.

1. Embedding participatory approaches in health projects

A recent study shows that certain actions - such as emergence of a core group, trust building, active use of participatory engagement strategies, aligning project goals with stakeholders’ needs - foster research processes, which in turn shift ownership and decision-making from researchers to community stakeholders. There are studies providing examples (see box for one of these) to demonstrate that citizen-led ownership of strategies and processes for health improvement can really help achieve positive health outcomes. Compared to conventional research processes, a participatory approach is often slow and demands time, but it allows citizens the space to explore, discuss, and investigate. It also allows researchers and citizens, together, to start with the knowledge that exists in the community, which is an empowering process, rather than teaching people how to take care of their health with a conventional, top-down intervention. A participatory approach helps bring to light the root causes of ill health and demonstrates interrelations between social determinants of health. Such processes are also mandated by the international conference on primary health-Alma Ata declaration and the World Health Organization’s approach to People Centred Care

A dengue prevention study in Nicaragua and Mexico tested the effectiveness of participatory research and community mobilization to control the spread of this endemic disease. The dengue pandemic had grown in spite of widespread interventions (for example, spraying of mosquito breeding sites) and there had been insufficient progress in reducing the spread. This study concluded that a community engagement approach where communities planned their own interventions of dengue prevention increased the effectiveness of dengue control. Such results had never been observed before when researchers used spray and pesticide interventions.

2. Using technology to monitor health challenges

Health projects have the potential to use technology not only to collect information from citizens but also to engage them. Technology can be used to generate citizen participation in measuring and confirming the quality of health care and in raising issues that hinder access or quality (see box for an example). Technology can gather real time data on citizen’s health status and their experiences of receiving care. Furthermore, it can ensure citizen participation at different stages such as piloting a program, implementation or during evaluation. 

A study on indigenous citizen-led monitoring efforts in Guatemala is currently underway, which is gathering user complaints using audio-visual evidence of the problems community members experience. Digital technology is offering citizens a way to engage actively in collecting data on access and quality of health services which feed into public policy processes. The study raises awareness about the right to health, and establishes communication channels and collaboration between indigenous communities and district health authorities to seek solutions.

3. Harnessing the power of the local through partnerships

Organizations that are committed to working with citizens, marginalized groups and women could be a solution in promoting community engagement and health for all. SDG Agenda 2030 encourages national and international organizations to partner with civil society organizations and policy research institutions that work with communities and citizens to promote inclusion. These organizations are able to work with citizens as well as communicate with a country’s researchers and policy makers to influence policies and challenge structural barriers. They play a crucial role in pointing out and trying to bridge the gap between the marginalized groups and the power holders. Canada, for example, has recently announced the Civil Society Partnerships Policy to maximize the impact of Canada’s international assistance. And globally, organizations such as Sarvodaya, Spatial Collective, and ATD Fourth World work with citizens and bring local resources, structure, values and technological skills to development projects. As a result, local communities receive support from grassroots organizations, allowing them to better structure their efforts and actively engage in these projects; this in turn leads to local ownership. Furthermore, civil society organizations and policy research institutions can connect community efforts to national plans and policies. This is a viable method to ensure sustainable representation and inclusion in policy processes. 

Developing openness within donors for a bottom-up agenda setting

Development donors play a crucial role in promoting and financing efforts such as the examples presented above, and so they are in an important position to initiate and sustain participatory development. Challenging though these methods may be, researchers, policy makers in both low and high-income countries and, in particular, donors are in a crucial position to enable conditions for community engagement.

Donors can promote, through the work they fund, models of engagement and empowerment. The Think Tank Initiative (TTI) provides an example of an empowering funding structure. TTI provides core, non-earmarked funding to 43 institutions to build local research, develop an independent research program and invest in public outreach that may influence policy.

Donors can ensure that citizens and marginalized groups are involved not only as information providers (through surveys and interviews) but as partners in different stages of a research (or a program) and in decision-making processes ‘at all levels’.This in factis a key phrase in SDG 16, target 16.7 which aims to ensure responsive, inclusive, participatory and representative decision-making. For example, participatory approaches are not only vital in the initial program-planning phase, but also during implementation and evaluation, and not only in a national setting, but also in global health governance and in funding scenarios.

Further, I believe that buy-in from donors to explore and integrate participatory approaches of funding arrangements is crucial to achieving health for all. Incorporating participatory approaches may challenge conventional agenda-setting processes within donor agencies, not least because things can take longer and there may be delays. Signing a contract and setting a common agenda between a donor and a recipient with a deliberative process will likely demand more time. If SDGs are to be welcomed ‘at all levels’, donors must be prepared to change funding processes that often start with a specific and rigid agenda that aligns with their goals and missions. They must be prepared to explore new funding options that are open to bottom-up agenda setting.

Put bluntly, these types of approaches will require donors at times to take a back seat compared to their more typical role in the current settings of donor-grantee relations. This may seem counter-intuitive, especially to funders who are concerned rightly with accountability, and the possibility of grants being misused due to lack of rigorous oversight and supervision. After the initial shock and slowness that may be encountered in comparison with more conventional project-based approaches, however, such efforts in reality are likely to grow towards more democratic methods of decision making to solve “development problems”. Building trust and transparency, an important step in development work, will actually help maintain accountability and boost learning and empowerment, and be key to ensure effective use of funds in through a more participatory, democratic setup. Ultimately, such practices can play a crucial part in disrupting the asymmetrical power relations that pertain in so many development processes.

I believe strongly that community and citizen engagement and organic participation hold great value in this SDG era and to bring health for all. Using participatory approaches at all levels, using technology to promote inclusion and monitor progress, working with grassroots organizations and incorporating a bottom-up agenda setting can lead to sustainable development and health for all. This might be a slower and a challenging journey towards achieving the SDGs, but I believe it will take us home, safely.