If you’re going to get stuck on a crowded elevator for an indeterminate period with the electricity going on and off, I couldn’t imagine a more affable, caring, resourceful, and good-humoured group of people to be with - MSF humanitarian staff from South and Central America, working on complex and important projects with some of the world’s most vulnerable (and made vulnerable) people, including migrants and Indigenous peoples. After some laughs and more serious actions to get ourselves out, I did ask how many doctors and psychologists we had aboard. After some 10 minutes, we were liberated from the steel hotbox. However, it was another bonding moment during an invaluable interactive gathering in Rio on the significant topic of engaging communities in humanitarian health responses, exchanging experiences and ideas, and learning tools and participatory approaches.
Some thirty Médecins Sans Frontières/Doctors Without Borders (MSF) colleagues from seven countries in South and Central America converged in Rio de Janeiro, Brazil from June 24 to 27 for a CommunityFirst Creative Lab, a workshop aimed at strengthening the capacity of MSF staff in the use of participatory methods for community engagement. SeeChange’s Dr. Violeta Chapela and Jessica Farber shared the learnings from the past two-and-a-half years of the CommunityFirst Transformational Investment Capacity (TIC) project, a joint initiative between MSF and SeeChange with the goal of innovating and strengthening MSF’s program delivery to ensure that communities are at the heart of humanitarian health responses. The project was piloted in Peru, Venezuela, and Sierra Leone.
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Renata Reis, Executive Director of MSF Brazil, the TIC project’s sponsor, shared that Brazil and the region have a history of working with communities. She said MSF Brazil is pleased to partner with SeeChange to pilot and disseminate tools, including the CommunityFirst Framework, and is committed to ensure that community engagement is integrated more systematically into MSF’s medical humanitarian work.
What does CommunityFirst mean? It is both an approach and a tool developed by SeeChange, based on the learnings of the TIC project and extensive research on participatory, community-based approaches in humanitarian work. It is based on the belief that communities are the first and extremely important responders to health and humanitarian crises. To improve health outcomes and resilience to future crises it is imperative to meaningfully involve, listen to, and collaborate with communities, especially those most excluded from health care.
We heard a common theme from MSF colleagues from Brazil, Venezuela, Colombia, Honduras, Guatemala, and Mexico, during the four-day meeting: the communities that they serve and collaborate with are often located in remote areas, or face barriers to accessing healthcare - such as migrants, Indigenous peoples, LGBTQI+, sex workers, and adolescents. Many of the communities are in countries and regions experiencing the negative impacts of conflict, economic and political crises, restrictive border and social policies, and extractive industries on health.
Watch a video about the workshop
Violeta and Jessica, together with Lia Gomes, Regional LATAM focal point on Community Engagement of MSF Brazil’s Brazil Medical Unit (BRAMU), Dr. Rachel Soiero, Medical Director of BRAMU, and Joanna Knight, Participatory Monitoring Evaluation Accountability and Learning (PMEAL) Lead, engaged the impressive group of health professionals in hands-on activities related to the four-phase cycle of the CommunityFirst approach: Connect, Engage, Activate, and Reflect.
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The participants engaged heartily in trialing CommunityFirst tools such as Stakeholder Mapping and Analysis, Emergent Learning Tables, and Stories of Change relating directly to their projects - from providing sexual reproductive healthcare services in Choloma, Honduras to medical humanitarian assistance to largely Indigenous and Afro-descendant river communities in the remote Pacific region of Chocó, Colombia, amidst ongoing armed conflict.
For our stakeholder mapping exercise, we tackled a real-life scenario in a small group: An MSF team at a migrant reception centre in San Vincente in eastern Panama is providing medical and mental healthcare to people who have spent between four and ten days crossing the Darien jungle to head north on South America’s only land route. On this perilous migrant route, people from several countries face brutal violence, including sexual violence, and risk injuries. Our hands-on activity was to consider how we could deeply engage with the community, which in this case is people on the move, as well as with local stakeholders, the government, and others. What are the barriers to engagement in a transitory, politicized context, and how do we incorporate anticipatory action into this project? Our group included individuals with direct experience in Panama, and with experience with migrants and community engagement in other countries. The powerful exercise helped us to think proactively and inclusively, guided by the CommunityFirst Framework.
What is the TIC? The CommunityFirst project is a collaboration between SeeChange Initiative and MSF Brazil, the project sponsor, supported by MSF’s Transformational Investment Capacity (TIC). The TIC invests “funds, intellectual capital and human resources to improve MSF’s ability to deliver urgent lifesaving care both now and in the future.”
In the “social mapping” exercise, MSF staff gave examples of why some of the ‘most vulnerable’ (or ‘made most vulnerable’) people risk not being included in health responses - because of their gender, ethnicity, age, social or citizenship status, or sexual orientation, for example - and how they can overcome this through new and adapted outreach strategies.
Participants reflected on the facilitator’s guidance that integrating the CommunityFirst approach should be part of regular planning rather than being considered an add-on, that collaborating with local community members throughout the project is essential, and that the approach needs to be adaptive and driven by each project and region’s context and unique social, economic, environmental, political and health factors. Participants also understood that monitoring and evaluation is integral to a community-centered approach, understanding and promoting impact, and should be driven by the communities’ view of success.
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Declaration of Alma-Ata 1978, International conference on primary health care: The Alma-Ata Declaration of 1978 emerged as a major milestone of the twentieth century in the field of public health, identifying primary health care as the key to the attainment of the goal of Health for All and addressing inequity in people’s health status. It reaffirmed, amongst other principles and goals: People have a right and duty to participate individually and collectively in the planning and implementation of their health care.
Participants reflected on the facilitator’s guidance that integrating the CommunityFirst approach should be part of regular planning rather than being considered an add-on, that collaborating with local community members throughout the project is essential, and that the approach needs to be adaptive and driven by each project and region’s context and unique social, economic, environmental, political and health factors. Participants also understood that monitoring and evaluation is integral to a community-centered approach, understanding and promoting impact, and should be driven by the communities’ view of success.
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Regardless of whether a humanitarian health program is an acute emergency response, a new project, or an established one that has been around for decades, I am convinced that using a CommunityFirst approach is crucial for the project’s success and that it is an ethically sound, pragmatic, and adaptive practice. It is grounded in best practices for collaboration with communities in health and humanitarian responses, and it is increasingly deemed an essential way of responding to cascading crises, such as environmental degradation and climate change, that exacerbate health issues. For example, MSF’s Environmental Pact of 2020 urges humanitarian workers to “engage and collaborate with communities'', alongside mitigation, adaptation, bearing witness, and accountability.
Communities must be at the center of humanitarian analysis and responses and be at the table for planning, implementing, policy-making, and advocacy. They also require increased access to resources. A trickle of humanitarian and climate finance reaches communities directly, despite commitments.
Communities often need and want support from experts such as MSF to realize their health solutions, but this support must adhere to the medical commitment to ‘do no harm’ and respect people’s right and duty to participate in their health responses. Communities are complex and not homogenous, they have agency and know their respective cultures, needs, and the local dynamics. It behooves us to work with them and aim to increase the impact and reach of our humanitarian endeavour so that all people can access needs-based and quality medical care.
These days in the Creative Lab have highlighted that while humanitarian projects to varying degrees already consult and connect with communities, pausing to consider how it is being done and how to improve, deepen, and embed this engagement is worthwhile. Also, the sharing of experiences, effective methods, and the trialing of tools, monitoring and evaluating our work in co-designing health responses is not only the right thing to do, but it also fosters a culture of engagement, learning, and reflection, and it is vital to addressing health inequities and improving health outcomes and advocating with fellow humans.
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