Health Promotion International, Vol. 18, No. 3, 189-197,
September 2003
© Oxford University Press 2003
Community participation in a rural community health trust: the case of Lawrence, New Zealand
Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand
Address for correspondence: Robin Gauld, Department of Preventive and Social Medicine, University of Otago, PO Box 913, Dunedin, New Zealand, E-mail: r.gauld{at}otago.ac.nz
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SUMMARY |
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Since the mid-1980s, the New Zealand health sector has been in a state of continual change. The most radical changes were in the early-1990s, with the creation of an internal market system for public health care delivery. Rural health services, seen to be unviable, were given the option of establishing themselves as ‘community trusts’, owning and running their own services. Community trusts have since become a feature of rural health care in New Zealand. An expectation was that community trusts would facilitate community participation. This article reports on a study of participation in a rural community health trust. The ‘pentagram model’ of Rifkin and coworkers, with its five dimensions of participation—needs assessment, leadership, resource mobilization, management and organization—was applied. High levels of participation were found across each of these dimensions. The research revealed additional dimensions that could be added to the framework, including ‘sustainability of participation’, ‘equity in participation’ and ‘the dynamic socio-political context’. In this regard, it supports recent theoretical work by Laverack (2001)
and Laverack and Wallerstein (2001). Finally, the article comments on the future of rural health trusts in the current round of health sector restructuring. Key words: community participation; measurement; New Zealand; rural health
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INTRODUCTION |
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TOPSUMMARYINTRODUCTIONCOMMUNITY PARTICIPATION AND THE...LAWRENCE AND THE STUDY...RESULTSDISCUSSIONLESSONS AND THE FUTURE...REFERENCES |
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Since the mid-1980s, New Zealand’s public health sector has been in a state of continual change, with four different structures for health care delivery. Details of the structures and changes have been discussed in-depth elsewhere [e.g. (Gauld, 2001
)]. The most radical restructuring took place in the early 1990s and involved the development of an internal market system, with a series of state-owned purchasing agencies contracting for services delivery with competing providers (public and private). It was assumed that this model would separate viable from unviable public services. The government recognized the high likelihood that remote rural hospitals would be unviable and that few competitors willing to run these would emerge. They proposed an alternative: affected communities could establish themselves as ‘community trusts’ to take ownership of local hospitals and health services, thereby ensuring their survival. The first such trusts were formed in 1992. During the latter half of the 1990s, as larger urban hospital owners of rural services facing increasing funding constraints withdrew from rural areas, community trusts grew in number. Most trusts were, therefore, an imposed option. Despite two subsequent restructurings of the New Zealand health sector (in 1996 and 1999), rural health trusts have remained a feature.
A range of expectations underpinned the original community trusts policy, and continue to do so. First, the government assumed that rural communities ‘would welcome the change to take control of [their health] facilities, and of the funding and provision of their health care services’ [(Upton, 1991), p. 17]. Secondly, that community trusts would configure services in ways that best meet the needs of their communities. Thirdly, that ‘Because they have control over trusts, communities may want to contribute local resources to their trusts’ [(Upton, 1991), p. 36]. Fourthly, and of significance to this article, it was envisioned that trusts would facilitate community participation in their decision-making, although the government did not specify how this might be done [(Upton, 1991), p. 35].
In 2000, a rural health trust in the New Zealand town of Lawrence was studied to probe whether the trust model was facilitating community participation. The aims of this study were to explore the broader concept of community participation in health services development and to consider which aspects were reflected in a practical setting. To investigate the latter, the ‘pentagram model’ of Rifkin and coworkers (Rifkin et al., 1988), which describes and ‘measures’ community participation, was used. The study also aimed to explore ways in which the current and future organization of primary care could improve community participation. This article reports the research results. The first section discusses community participation and the pentagram model. The second backgrounds the Lawrence study and methodology employed. The third section presents results, followed by a discussion. The conclusion considers lessons from the study and the future of rural health care organization in New Zealand.
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COMMUNITY PARTICIPATION AND THE PENTAGRAM MODEL |
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Community participation has been part of policy rhetoric in both developing and developed countries, and has been conceptualized and defined in varying ways. In 1969, embracing a broad notion of community involvement, Arnstein (Arnstein, 1969
), using a ‘ladder’ analogy, proposed differing degrees to which a community has links to power. The lower rungs of the ladder represent non-participation by manipulation. Next are degrees of tokenism and consultation, followed by higher levels of citizen power such as partnership and delegated power. Ultimately, at the top of the ladder, is citizen control. Rifkin and colleagues later defined community participation as: ‘a social process whereby specific groups with shared needs living in a defined geographic area actively pursue identification of their needs, take decisions and establish mechanisms to meet those needs’ [(Rifkin et al., 1988), p. 933]. In terms of participation in a small rural community health trust such as Lawrence, such a definition might be considered appropriate as the numbers of participants are likely to be limited, as would be the ‘levels’ of access to power.
While community participation is generally viewed as having a positive role to play in health care, debates over its meaning and how it might be measured continue [e.g. (Jewkes and Murcott, 1996; Lupton et al., 1998)]. Furthermore, there has been little systematic evaluation of the processes involved in community participation (Schmidt and Rifkin, 1996). Rifkin (Rifkin, 1996) contends that community participation is often referred to in rhetoric but difficult to translate into reality, and it is acknowledged in the literature [e.g. (Laverack and Wallerstein, 2001)] that there have been few attempts to operationalize this complex concept.
The relationship between community participation and health outcomes is important, yet cannot easily be ‘quantified’. Numerical indication of the range of activities in which a community is involved is not considered an adequate measure of participation, capturing neither the dynamics and changes associated with participation nor the ability to achieve change (Simpson, 1999). Similarly, quantitative methods may be unable to explore the all-important processes of participation. As Zimmerman argues, community participation and empowerment is a dynamic experience and not a static outcome (Zimmerman, 1995). Therefore, to understand and measure community participation, there is a need to use process indicators.
There has been limited research to date into community participation processes. This has largely entailed application of the pentagram model, which was the first attempt to apply a practical method for measuring participation processes in health care delivery [see (Rifkin et al., 1988)]. Following analysis of more than 100 case studies, Rifkin and coworkers identified five dimensions influencing participation that could be incorporated into an analytical pentagram framework (Rifkin et al., 1988): needs assessment, leadership, resource mobilization, management and organization. Each dimension was assessed through a series of questions and numerically ranked along a spectrum from narrow to wide participation. As illustrated in Figure 1, wide participation along any of the dimensions would be indicated by a higher score. Rifkin and coworkers (Rifkin et al., 1988) envisaged that the framework could be used to compare different programmes, the findings of different assessors of the same programme or different participants in the same programme, and changes in the level of participation over time.
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Rifkin and coworkers (Rifkin et al., 1988
) left open the questions of who should conduct participation evaluations or what sorts of data ought to be collected, and varying approaches have been taken. They performed the rankings based on interviews with community leaders. Bjaras and colleagues used multiple data sources, including questionnaires, interviews and a log book (Bjaras et al., 1991). Elsewhere, the community themselves ranked the extent of participation (Matheson, 1990). |
LAWRENCE AND THE STUDY METHODOLOGY |
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Lawrence was selected for the study after the appraisal of a number of trusts. The Lawrence community had an 8-year history of running a trust, having been one of the first pilots established in 1992. The Lawrence trust was also in a comparatively advanced developmental state, and involved people active in health issues beyond their own community who were willing to share their experiences.
Lawrence, which is 80 km inland from the New Zealand South Island city of Dunedin, has a present population of ~474 and is the service centre for the Tuapeka rural farming district of 2000 people. Current health services are provided out of the ‘old hospital’, recommissioned as the Lawrence Rural Health Centre. This houses a general practitioner supported by a practice nurse, and two registered nurses overseeing centre in-patients. Table 1 lists Lawrence’s primary care services. Visiting staff provide additional services such as dentistry, meals on wheels, podiatry and physiotherapy.
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Interview data were used for the ranking exercise. Study participants were purposively sampled, in accordance with their richness of experience in the establishment and/or ongoing involvement with running the trust. Seven potential participants were identified, and each agreed to partake in the study (see Table 2
). These people were all current members of the trust board, the Tuapeka Community Health Support Group (a fundraising forum, which is discussed below) or health centre employees. All had been involved in forming the trust and had knowledge of its development and current situation. When interviewed about their involvement, those selected were clearly motivated by a desire to contribute to developing the community and its health services. The number and range of those interviewed could have been extended beyond the board, its supporters and service providers. However, in keeping with Rifkin’s definition of participation (above), those who ‘actively pursue identification of their needs, take decisions and establish mechanisms ...’ were targeted.
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The semi-structured interviews, based around the questions developed by Rifkin and colleagues (Rifkin et al., 1988
) and Bjaras and coworkers (Bjaras et al., 1991), were taped, transcribed and categorized under the five pentagram dimensions. The ranking exercise was then performed. The criteria against which rankings, based on the interview data, were made are listed in Table 3. Establishing the criteria proved difficult, as descriptions for each position on the continuum relevant to the Lawrence trust had to be developed. To validate our rankings, a copy of the results and the ranking tables was sent back to the interviewees who were invited to comment and give their own scores. The six interviewees who responded largely concurred with our rankings.
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For analysis, Rifkin and coworkers’ five-point scale for the ‘resource mobilization’, ‘needs assessment’ and ‘leadership’ categories was used (Rifkin et al., 1988
). These were distinct categories with sufficient intra-category variables to consider on a wider scale. However, features common to both the ‘organization’ and ‘management’ categories meant they were difficult to separate from one another. These categories were therefore mapped closely together on the pentagram (see Figure 1
), and a three-point scale [as used by (Bjaras et al., 1991)] was adopted to maintain intra-category differentiation and the distinction between organization (structures) and management (relationships). |
RESULTS |
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Resource mobilization
Resource mobilization was ranked 5 out of 5. All interviewees believed the community’s contribution of resources to develop and maintain the Lawrence Rural Health Centre and services had been generous and extensive. This included providing labour, material and financial donations, and mobilizing other funding. The community was asked to raise $NZ30 000 to transform the old hospital into the new centre, and produced double this figure. They also produced innovative ideas for support. For example, the community arranged for the celebrity television ‘Maggie Barry Garden Show’ to document a 24-h community-sponsored makeover of the centre gardens. An important component of community organization is the Tuapeka Community Health Support Group (TCHSG), composed of representatives from the district served by the centre. This group evolved out of an earlier group which fundraised for the ‘old hospital’, and was instrumental in setting up the trust. The support group has fundraising and community relations functions. It facilitates the community’s contribution to running the centre, enabling the board of directors to focus on management issues. Support was also evident in the fact that 240 households (in a district of 2000 people) became paid-up members of the trust. Thirty-one groups from Lawrence and the wider district contributed to centre renovations. Most of the centre’s funding is from the government, supplemented by patient co-payments and fundraising. The board of directors and TCHSG are volunteers. Ongoing sustainability of resource mobilization (whether the community could maintain its contribution) emerged as a crucial issue, not currently captured by the pentagram framework, although a longitudinal study might satisfy this. Responding to our ranking, the interviewees gave the Lawrence performance the following scores: 4/5, 4/5, 4/5, 4/5, 5/5 and 5/5.
Needs assessment
Needs assessment was ranked 4 out of 5. While the trust canvasses community views, the focus has been on services rather than broader health needs. There was no consideration (within the pentagram framework, or within Lawrence) of whether participation in needs assessments was equitable, nor whether unheard groups’ needs were overlooked. It was not clear how Lawrence’s original needs assessments had been conducted. One was undertaken in 1992 when establishing Lawrence as a pilot community trust (Tuapeka Community Health Company, 1994). This included a stocktake of existing services, their effectiveness from a user perspective, potential threats and opportunities for the trust, and service alternatives. Contemporary needs assessment consists of community consultation through the TCHSG, the local media and other community groups. The TCHSG conducted a household survey in 1999 to assess awareness of and satisfaction with services, and to gather information on additional services needs. Among the 54 returned surveys, the most frequent request was for a dentist. Dental services were subsequently made available at the centre. Interviewees suggested that such a survey should be run triennially. The interviewees ranked the Lawrence performance as follows: 4/5, 4/5, 4/5, 4/5, 4/5 and 5/5.
Management
The management ranking was 2.5 out of 3, as external funding contracts with central government agencies are an influence over which the community has little control. However, strategic management decisions are made by the board and can influence external funders. Discretionary day-to-day management issues are largely joint decisions by health professionals and the Lawrence trust. The annual plan, budget and objectives are considered an important part of the management process. Contributing to this are the centre manager, the accountant, the directors and the support group who report back from the community. The general practitioner has a certain amount of autonomy as a subcontractor to the trust but, where the need arises, decisions about general practice management are taken by the board. Board members considered that they have a ‘comfortable relationship’ with one another, and make decisions by consensus. Finally, the health centre manager routinely attends board meetings. Interviewees expressed concern about the ever-changing external environment of the New Zealand health sector, and the effects of this and the changing local context on the running of the trust, a dynamic not captured in the pentagram framework. Interviewees gave management performance the following scores: 2.5/3, 2.5/3, 2/3, 3/3, 2.5/3 and 2/3.
Organization
Organization was ranked 3 out of 3, as the Lawrence trust fulfilled criteria laid out in previous studies [(Rifkin et al., 1988; Bjaras et al., 1991); see also Table 3]. A wide range of groups were involved in the trust, including the ‘owner’ (the Tuapeka Community Health Company and board), health centre staff and the TCHSG. The latter, the primary source of company directors, arose out of the long-lived ‘Friends of the Hospital Committee’. Ownership of facilities is vested in the community to raise the sense of community investment. The Lawrence trust has taken a lead role in forming a collaborative network of regional rural health trusts, seen as a way to create strength in numbers, while sharing ideas and experience in dealing with central government and funding agencies. The interviewees ranked ‘organization’ as follows: 3/3, 3/3, 3/3, 3/3, 3/3 and 3/3.
Leadership
We ranked leadership 4.5 out of 5. Lawrence leaders largely emerge through a process of self-selection and commitment to volunteer work and community service. Interviewees suggested that there was nothing to stop any group or individual from representing themselves at the leadership level. Some interviewees acknowledged a lack of representation from marginalized (i.e. disadvantaged) groups/sections in the community. Some viewed this as a failure on the part of the community organization to meet population needs. One interviewee mentioned the relatively homogeneous nature (similarity in age and level of affluence) of members of the TCHSG, considered to be the ‘harvest area’ for directors. Another saw marginalized groups with their own agenda as a potential threat in that certain people, not considered ‘legitimate’ members of the community, could take over health centre ownership and management. On the other hand, all interviewees became involved at the outset out of genuine concern for continuation of the district’s health services. There was a suggestion that leadership had an obligation to fight against services being relocated out of the region as this has a negative impact on other services and the viability of the trust. This had been the case with pharmacy services, now only accessible from a town 40 km away. Interviewees ranked leadership as: 4/5, 4.5/5, 4.5/5, 4.5/5, 5/5 and 5/5.
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DISCUSSION |
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TOPSUMMARYINTRODUCTIONCOMMUNITY PARTICIPATION AND THE...LAWRENCE AND THE STUDY...RESULTSDISCUSSIONLESSONS AND THE FUTURE...REFERENCES |
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The research discussed in this article suggests that a community health trust, at least in the case of Lawrence, can promote community participation. Having said this, Lawrence has a history of a robust community, and anecdotal evidence suggests that other rural health trusts in New Zealand are experiencing difficulty facilitating participation.
The pentagram framework was useful in terms of highlighting five processes of community participation seen to be relevant to, and exhibited to varying degrees in, Lawrence. The framework, with its qualitative method, enabled a focus on these important processes while allowing for wide-ranging exploration of issues as they arose. In this sense, it elicited issues not necessarily central to processes of participation, but considered to influence the extent or type of participation experienced. As noted in the Results section above, these factors could be grouped under headings of ‘sustainability of participation’, ‘equity in participation’ and ‘the dynamic socio-political context’, which characterize the successively restructured New Zealand health sector and societal changes. While they could be incorporated as subcategories of the five existing pentagram dimensions, it might also be useful to add these as separate dimensions.
After the Lawrence research was completed, Laverack and Wallerstein (Laverack and Wallerstein, 2001) proposed a ‘community empowerment’ framework that intersects with, and contains additional dimensions to, the pentagram model. This seeks to gauge: (1) participation, (2) leadership, (3) problem assessment, (4) organizational structures, (5) resource mobilization, (6) links to others, (7) ‘asking why’, (8) programme management, and (9) the role of outside agents [see also (Laverack, 2001)]. It links interpersonal elements (individual control, trust and cohesiveness) with socio-political, economic and cultural contexts. Our research provides practical support for this expanded framework, revealing information that would fit under most of these headings. For instance, ‘asking why’, which is about the political and social context in which community participation is advocated, clearly relates to the ‘dynamic socio-political context’ noted above.
There were shortcomings in utilizing the pentagram framework and with the Lawrence study. First, the measurement process is inherently subjective. The fact that our interviewees largely concurred with our rankings gave us some assurance that our findings reflected the Lawrence case, at least from their perspective. Secondly, the findings reflect only the views of those most involved in the Lawrence trust, including community representatives. The framework does not focus on those who do not participate (as interviewees intimated) and potentially under-investigates the citizen or client role in the community participation process (Ryan, 1978; World Health Organization, 2000). It is possible that the interviewees had a vested interest in promoting the trust and, therefore, in painting a more positive picture than may have been received in a broader study. We do not know whether the ‘disadvantaged’ groups mentioned by an interviewee, for example, pose a threat to the Lawrence health trust status quo, have differing views from those interviewed, or see themselves as subject to token consultation by the trust. Thirdly, as Rifkin and coworkers (Rifkin et al., 1988) suggest, the framework is unable to assess the extent to which participation processes contribute to improving health gain or reducing inequalities. In future applications, it may be useful to ask communities ‘Why is community participation being encouraged?’ and ‘Who stands to gain by the community being involved?’.
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LESSONS AND THE FUTURE OF NEW ZEALAND’S RURAL HEALTH TRUSTS |
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The Lawrence study spawns lessons for rural health care organization in New Zealand and elsewhere. First, there is utility in seeking to gauge participation in community health care governance, if participation is a policy requirement. The Lawrence study found strong levels of participation, at least within the parameters of Rifkin’s definition and measurement framework, along with areas where participation could be improved. Secondly, the Lawrence trust was chosen as it was advanced compared with other New Zealand health trusts. It could be a significant challenge for researchers seeking to measure participation in communities that lack the basic infrastructure studied through the pentagram model, such as governance, and organizational and participation arrangements. Thirdly, as a heuristic device, the tools employed in the Lawrence case proved useful, but could be developed further along the lines discussed above. Any study could also be expanded to encapsulate a broader community, considered in relation to both internal and external links with power, in accordance with Arnstein’s ladder notion.
What is the future of health trusts such as Lawrence, compelled into existence through government policy? The New Zealand health system has recently been restructured into a series of semi-elected ‘district health boards’, with planning and purchasing functions previously performed at a national level. Meanwhile, the government is demanding the formation of ‘primary health organizations’, each serving ~30 000 people, which are required to facilitate community participation in service governance and planning. Consequently, rural trust funding contracts have been devolved to the district level, preoccupying trust members, and it is possible that inter-trust organizations will form to fulfil primary health organization requirements. Where this leaves the character and spirit of individual community trusts such as Lawrence is uncertain, as is the nature and extent of the ‘participation’ required by the government.
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ACKNOWLEDGEMENTS |
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Our utmost gratitude is extended to the interviewees for their willing participation in the Lawrence study. Thanks to Associate Professor Rob McGee (Department of Preventive and Social Medicine, University of Otago) and the two anonymous referees for comments on an earlier draft of this article. We also wish to thank the University of Otago for providing financial support for the study.
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REFERENCES |
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Arnstein, S. (1969) A ladder of citizen participation. Journal of the American Institute of Planners, July, 216–223.
Bjaras, G., Haglund, B. and Rifkin, S. (1991) A new approach to community participation assessment. Health Promotion International, 6, 199–206.
Gauld, R. (2001) Revolving Doors: New Zealand’s Health Reforms. Institute of Policy Studies and Health Services Research Centre, Wellington.
Jewkes, R. and Murcott, A. (1996) Meanings of community. Social Science and Medicine, 43, 555–563.
Laverack, G. (2001) An identification and interpretation of the organization aspects of community empowerment. Community Development Journal, 36, 134–145.[Abstract]
Laverack, G. and Wallerstein, N. (2001) Measuring community empowerment: a fresh look at organizational domains. Health Promotion International, 16, 179–185.
Lupton, C., Peckham, S. and Taylor, P. (1998) Managing Public Involvement in Health Care Purchasing. Open University Press, Buckingham, UK.
Matheson, D. (1990) Primary Health Care—The Experience of Four Communities (information booklet and video). Newtown Community Health Centre, Wellington.
Rifkin, S. B. (1996) Paradigms lost: towards a new understanding of community participation in health programmes. Acta Tropica, 61, 79–92.[CrossRef][Web of Science][Medline]
Rifkin, S. B., Muller, F. and Bichmann, M. (1988) Primary health care: on measuring participation. Social Science and Medicine, 26, 931–940.
Ryan, D. (1978) Organisation of health services. New Zealand Hospital, March, 19–24.
Schmidt, D. and Rifkin, S. B. (1996) Measuring participation: its use as a managerial tool for district health planners based on a case study in Tanzania. International Journal of Health Planning and Management, 11, 345–358.[CrossRef][Web of Science][Medline]
Simpson, J. (1999) Community Injury Prevention Projects: an evaluation of two pilot projects in Kawarau and Rangiora, New Zealand. MPH thesis, University of Otago, Dunedin.
Tuapeka Community Health Company (1994) Tuapeka Community Health Company Concept Report. Tuapeka Community Health Company, Lawrence.
Upton, S. (1991) Your Health and the Public Health: A Statement of Government Health Policy. Government Printer, Wellington.
World Health Organization (2000) The World Health Report 2000. Health Systems: Improving Performance. WHO, Geneva.
Zimmerman, M. A. (1995) Psychological empowerment: issues and illustrations. American Journal of Community Psychology, 23, 581–599.[Web of Science][Medline]
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