Relationality in Community Engagement: Its Role in Humanizing Health and Achieving Quality Integrated Health Services

"Overall, the key message from the report is this - people change systems."

Our communities and social connections define who we are as much as we define the many communities that we belong to - many concurrent - in our lifetime. Community engagement in health is informed by multiple and diverse disciplines and professions that address the continuum of social connection. This relationality recognises that community engagement is a shared responsibility across the health system. Developed by the World Health Organization (WHO) and the Qatar Foundation for Education, Science and Community Development (QF), this report introduces the background and current policy context for community engagement across different WHO regions.

As outlined here, many health systems operate in a fragmented model, where services are often disconnected from the population's social and cultural contexts. This inconsistency within health systems contributes to inequities in access to care, poor quality of services, and poor health outcomes. In this context, relationality incorporated into the way staff in health systems engage together and outward with communities is vital in settings marked by deep-rooted historical trauma and social injustice, helping to rebuild trust, foster reconciliation and enhance community resilience. Relational community engagement supports ongoing efforts of health promotion, health literacy approaches, and recognition of the social determinants of health to improve solidarity for health.

WHO regional resolutions and strategies recognise community engagement as a necessary condition to address a broad range of public health challenges. While each region faces unique public health challenges, common priorities include:

• integrating community engagement into health systems;
• building trust and empowering communities through capacity building and social prescribing;
• ensuring inclusive participation, particularly of marginalised groups, in decision-making;
• fostering cross-sector collaboration;
• enhancing community resilience;
• using data-driven approaches to inform actions; and
• securing long-term sustainability through adequate funding and governance.

For this report, the International Federation of Social Workers (IFSW) conducted focus group research with social workers from diverse contexts. For effective community engagement, they recommend:

• a genuine approach to co-building partnerships;
• skills within the health authority of recognising and working with community leaders, as well as understanding the resources that communities can bring to health outcomes;
• recognition that communities are made up of diverse populations, which may require a unique approach within a broader community engagement approach;
• an understanding that people must be seen holistically rather than as bearers of illness;
• agreement to co-design, co-produce, co-learn, and co-evaluate;
• recognition that communities are both geographical and issue-based;
• conception of engagement as an ongoing process that requires time, commitment, and resources for all sides; and
• responsibility on the part of the state for financial resourcing.

With this foundational background shared, the report presents an Integrated Change Framework (ICF) to embed and strengthen community engagement processes in health system functions and activities. The ICF emphasises that health services are delivered by people for people. Health systems rely on networks of interdependent relationships for administrative, clinical, technical and operational functions. These relationships are often overlooked or inadequately considered in strategic planning and policymaking.

The ICF figure on page 8 summarises the key themes emerging from the literature and reviewed case studies. Each component is interrelated and operates as a whole. The four foundational elements in the ICF - (i) social and contextual data integration; (ii) participatory facilitation and convening skills, methods, and tools; (iii) system-wide communication, collaboration, and integration; and (iv) leadership, management, and governance - capture and incorporate key commonalities, lessons learned, and best practices into an approach that embeds community engagement principles and processes and strengthens relationality across all aspects of health service programming.

The ICF highlights a fundamental change end point: the ability of individuals and teams to provide holistic, integrated, and responsive health services. Having this goal requires strengthening of relations within and between teams. To that end, the ICF can facilitate strategic and operational discussions on health service performance and measurement.

Case studies shared in the report from Ethiopia, Lao PDR, Qatar, Sierra Leone, Thailand, the United Kingdom, and the United States - spanning all WHO regions, diverse contexts, and various entry points for community engagement - have informed the development of the ICF. The case studies highlight relationship and trust building across different levels and between different stakeholders.

The report concludes with recommendations for applying the ICF to improve health system performance. Governments are encouraged to focus on the following aspects.

1. Promote relational leadership, management, and governance - for example:

• Invest in adaptive, transformative leadership models to drive whole-system learning.
• Develop political commitment to adopt a relationship-focused approach to community engagement as an inherent way of working in health systems and across sectors.
• Engage the health and care workforce and civil service across sectors to develop a renewed vision for public sector values and ways of working.

2. Strengthen relationship-building capabilities in health systems - for example:

• Strengthen communication and collaboration in health systems, setting relational competency benchmarks and invest in local capacities of communities to address power imbalances.
• Develop participatory skills in multi-disciplinary teams and interprofessional practice.
• Integrate social and contextual data in health service design and delivery.

3. Invest in transdisciplinary research and practice development - for example:

• Fund research using the ICF to foster collaboration across the sciences, technology, and the arts.
• Ensure that evaluative requirements for research impact include the cost-benefit analysis of social interventions connected to relational and social outcomes to promote health and wellbeing.
• Establish relational aspects as a criterion in funding proposals for community engagement research.

In conclusion, this report has made the case that relationality in community engagement can: enhance patient care; promote collaboration, connection and belonging; address the social determinants of health; improve equity; and integrate lived experience and holistic knowledge systems through community-centred approaches to health and well-being.