Implementing Community Change
At this point in HumanaNatura’s process of promoting an agenda for improved health in your community, your Health Action Group is up and running. It has an organizational structure and established procedures for managing itself, and ideally a commitment, in principle and practice, to ongoing pragmatism, learning, mutual respect, and openness toward its members, its stakeholders, and the community generally.
Your Health Action Group also now has have a well-defined and careful-considered Community Vision and Community Health Agenda of 3-5 health promotion actions that are the principal subject of its attention and efforts. Each health promotion action, in turn, should be guided by a campaign leader and/or working campaign team, and have a thoughtful and perhaps a quite creative health advocacy campaign.
As we have discussed, it is essential that each advocacy plan include careful consideration of both the facts and politics surrounding each proposed health action. This includes reasonable fluency with applicable health science and consideration of the available technical options available to the community and their relative merit (including the tangible and intangible costs and benefits, and relative risks or uncertainty of each option). Sometimes, the advocacy plan will pursue technical options other than those originally conceived for the health issue during the community assessment and issue prioritization.
At the same time, each advocacy plan must ensure facility with the political landscape of the community as respects the action, and embody a clear and accurate sense of what is possible, or what might be possible, with a well-orchestrated health advocacy campaign to promote change. As summarized in the previous section, this part of the a health advocacy plan will include a detailed and credible stakeholder analysis that gauges expected community support and resistance, the key issues underlying these dynamics, and thoughtful influencing strategies to move the community to an position of support for the action.
In the realm of technical considerations, options for action or change can vary widely. If an action is incremental to community life or makes use of established competencies within the community, the campaign may simply involve getting existing people or organizations to act in slightly altered ways. On the other hand, at least some of the technical options that will arise in the various health issues in your long-term agenda are likely to involve wholly new capabilities for the community or the building of new systems, structures, and social norms into community life. If these options are pursued, considerable more technical and political pre-work will of course be required.
Many options for change, of course, will lie between the extremes of high simplicity and high complexity. These technical options may involve altered models or methods for existing actors or organizations, the redeployment of work and responsibility within the community, or added responsibilities or an extension of existing capabilities into new areas. In any case, detailed consideration of scientific and practical issues must be included in each advocacy plan, even if the action is simply to secure community resources to study options for longer-term solutions to an issue.
In addition to technical considerations, careful consideration of political and social realities within the community for each advocacy plan is at least as essential, and must include cogent assessments and influencing strategies for the individuals and groups who will be key stakeholders in eventual actions. Each advocacy plan’s political analysis should include consideration of all relevant governmental and regulatory stakeholders, major community groups, and of course people and groups immediately affected by the change.
Each stakeholder analysis also should consider multiple options to raise awareness and mobilize support for action, and present clear tactics for influencing stakeholders and creatively communicating issues in the community. That said, stakeholder influencing and issue presentation must never unethically mislead or otherwise risk erosion of support for future health-based action – for example, by engaging in intentionally inflammatory communication or divisive issue framing.
Like your Health Action Group’s overall vision and agenda, each advocacy plan must equally leave room for learning and adjustment. In a sense, each plan must plan for the unplanned. This is accomplished by soliciting feedback and taking in additional viewpoints and information, especially as campaign leaders and/or campaign teams move from building consensus for action across your Health Action Group to achieving this same outcome across your full community and its potentially far more diverse set of outlooks.
Inclusion of added views and information is normally best accomplished by holding regular reviews within the working campaign team, and by providing periodic updates to the full Health Action Group (and to your community’s health board or full governing council as needed). These input sessions of course can be held both as a potential action is initially analyzed and then as a health action campaign is developed, vetted, and implemented.
Going “live” on a health issue
When an campaign leader and/or campaign team has mastered both the technical and political planning issues surrounding an intended health advocacy effort, its campaign document is finalized, and then reviewed and approved (or sent back for further refinement) by the Health Action Group or its executive committee.
With approval by the group, the campaign leader and team are ready to begin campaigning for the specific health-promoting change in your community. But where should each specific campaign begin and how? Let’s consider each of these critical implementation issues.
> Where to begin a campaign – it is usually easy to answer this question and a detailed action plan should always be detailed in the campaign document prior to its approval by the Health Action Group. In almost all cases, the working group for an issue will focus considerable initial attention and action in two areas:
- Decision-makers – those people who ultimately have formal authority to decide the matter and make resources available for the desired action
- Interested parties – stakeholders most affected by the change or decision-making process, including those who will be tasked to implement change
As discussed before, the stakeholder analysis of the campaign document should identify these individuals and groups, as well as others who may significantly influence, be impacted by, or be interested in the action (whether positively, negatively, or neutrally), and include plans for initial contacts and follow-up interactions with them.
Since all community health promotion actions, however modest, must ultimately drive a change or commitment of resources, each advocacy campaign must focus attention on the decision-maker(s) that control resources – while being mindful of impacted and competing stakeholders, and the immediate and long-term effects of the health promotion action within the community. While an advocacy plan will often entail the involvement and influencing of people who are not decision-makers on the action you want to implement, it usually best to start with the decision-makers themselves and then quickly follow this initial contact with outreach to other primary stakeholders.
Starting with decision-makers often offers two important advantages. One is simply efficiency. After all, there may be strong and perhaps unexpected receptivity by your decision-makers, allowing your campaign team to get a quick yes and be able to move on to implementation and new agenda items. This is often the case when actions are easy and impactful, and when the issue has been thought through technically and politically from multiple perspectives.
The second advantage of starting with decision-makers is transparency, which helps you achieve immediate high ground in your advocacy effort and may offer valuable new information on the issue. In the very least, by beginning and being open with decision-makers and key affected parties, you will be respectful and transparent with the community leaders you must persuade (or, in the extreme, replace) and other interested parties you must win over (or again, in the extreme, overcome) to succeed with the health campaign.
> How to begin a campaign – the way to begin a campaign can be more complex and will depend on circumstances, but again should be detailed in the advocacy plan document prior to approval. In general, it is advisable to begin informally via a direct discussion of the issue, first with your decision-makers and then with your affected groups, explaining in plain and personal terms what you want and why.
As we said before, this approach is at least courteous and often is an effective approach to promote change, without the work of marshalling a larger community effort. In informal preliminary meetings of this kind, it is advisable not to make a (formal) presentation, but instead to plan for and facilitate the two-way discussion and sharing of views that informal meetings are so good for.
To this end, a few pages summarizing the science of the issue, options considered, your cost-benefit analysis, and proposed implementation plan can be useful discussion aids, and may help your issue leader or team to show respect, inform and address concerns, encourage reciprocal information sharing, and build credibility and trust.
Getting to “yes” on an issue
In some cases, especially those involving easy steps with at least a modest short-term community benefit, your informal discussions with decision-makers and primary stakeholders may trigger a chain of events that get your desired action accomplished reasonably quickly.
But at least as often, this will not be the case. Decision-makers, stakeholder groups, and people responsible for implementing change may not be receptive to your ideas and may perhaps not even agree to meet (though this latter situation is uncommon in the case of organized and active community groups). In these cases, you and your working group will need to be prepared to mobilize sufficient community support to ensure a successful campaign and positive health-based change, though once again always with an eye to the long-term and increasing total support for your overall health promotion mission, vision, and agenda.
When you face significant opposition and need to mobilize support – whether for gaining approval of an action or ensuring its successful implementation – inevitably you will need to consider the amount and type of community support you require.
Often, but not always, the correct answer to the question of support mobilization is just enough and no more. Why? Because many forms of mobilization, especially on controversial issues, come at a cost, even as some forms of mobilization can build new community health awareness and create a net benefit for the future. In general, mobilizations on actions that are easy and understandable, and produce clear immediate benefits to many people, tend to cause mobilization benefits to exceed costs.
Many health promotion actions, however, will not have these qualities, and this often proves true with actions that face immediate and strong push-back. These may be actions that will not be well-understood by the community until after implementation, or that involve immediate costs for eventual benefits, or that impact the community disproportionately. In these cases, mobilization costs may exceed benefits, especially as mobilization efforts expand beyond strong supporters of the action. In these cases, care with mobilization is critical, so that long-term support for your group is increased and not diminished.
In all health advocacy campaigns, the campaign leader, campaign team, and Health Action Group will want to preserve or increase its political capital for the long-term to the greatest extent possible, while getting to successful outcomes in the short-term. Often, but not always, this means successfully completing campaigns and providing positive benefits efficiently and with minimal friction (even as attention-getting and friction-producing flair will be required at times). In practice, the underlying message of thoughtful campaigns and quiet success is competency and power, perhaps showing the community that members of the Health Action Group are not just good health advocates, but potentially goof future community leaders as well.
If you or others are initially rebuffed in informal meetings with decision-makers, key stakeholders, or implementing organizations, it is easy to become stressed or emotional, and react disproportionately and less than optimally to the situation. If a campaign leader or team feel emotions rising, it is almost always best to step back and take stock of your needed next steps. Seek the advice and perspective of members of the Health Action Group or others you respect and trust, particularly people who are not immediately involved or invested in the advocacy campaign (and who thus may bring a very different and helpful perspective).
Once an air of calm is restored, it will be time to revisit the stakeholder analysis and influencing strategies, any technical information that has been questioned, and the overall campaign plan. Perhaps the analysis and planned steps may need to change based on your initial discussions with decision-makers and stakeholders, but perhaps not.
In any case, if initially rebuffed, you will now need to begin the process of mobilizing community support – in ways and amounts sufficient to influence the required decision-makers and stakeholders and create the change you seek. The needed steps toward community mobilization will vary according to circumstances, but normally should favor ones involving creativity and subtlety rather than force and threats. A pre-planned and stepped or graduated pathway for issue mobilization should be included in each advocacy plan, and again always should be regularly reviewed and improved as campaigning and then implementation proceeds. This is especially important on controversial issues or when there is unexpected or strong opposition.
Whatever the specifics and circumstances of a particular campaign, the overarching goal in all mobilizations again will be to mobilize support optimally. Issue leaders and teams want the right amount and kind of support to get the action accomplished – never under-mobilizing, over-mobilizing, or mis-mobilizing the community and supporters on an action or issue. Judgment and experience will help in this, but so will an incremental or graduated approach to building support for an issue. This approach is often most effective, since it allows a campaign team to either stop, continue, or alter mobilization as circumstances dictate.
An example of an incremental approach to community mobilization might be as follows, with each successive step initiated only if a favorable decision on the campaign goal is not achieved in the previous step:
Example of a graduated community mobilization plan
- Meet informally with decision-makers and stakeholders to discuss action and rationale
- Respond to concerns & meet again informally with decision-makers and stakeholders
- Hold information sessions in the community and brief 500 people on the issue, and provide feedback on the sessions to decision-makers
- Meetings with local reporters and media
- Enlist a group of 50-100 supporters to write to resistant decision-makers
- Follow-up informally with decision-makers & seek to explore alternatives
- Enlist a group representing 10% of community to sign a petition for consideration of issue
- Follow-up informally with decision-makers & seek to explore alternatives
- Schedule discussion of issue at governing council meeting & ensure 50+ supporters attend
- Discuss issue in press and begin neighborhood meetings to mobilize commitment to action
- Schedule discussion of issue at governing council meeting & ensure 100+ supporters attend
- Identify one or more candidates to run against resistant decision-makers at next election
As you can see, this graduated approach can stop as soon as the desired action is achieved, minimizing community effort and the risk of weakening of political support. But the effort also can continues until success is achieved, up to and including replacement of political decision-makers. This last point is quite important.
In HumanaNatura’s overall approach to community health advocacy, inaction on a selected health action and approved health campaign is not an option, even as alternative actions and compromises are – as long as progressive health-promoting change is realized and expanded community support is engendered for the future. Continued and graduated pressure is used to ensure a successful outcome in each campaign, and successful campaign is used to build momentum for future health-promoting change.
These ideas underscore our earlier discussions of the need for thoughtfulness and care in the formation of your Health Action Group’s Community Vision and Community Health Agenda, and during the review and approval of its health advocacy campaigns. All of your group’s primary agenda items at any point in time must be technically feasible and beneficial to the community in proportion to their costs. All approved campaigns must be realistic and politically winnable in the short to medium term. And all campaigns must involve issues your group is willing to see through to successful resolution (and thus use to build support for additional health promotion actions).
If an action is not at least somewhat impactful, it should not be on your Health Action Group’s agenda. If an action is not winnable, the campaign for it should be delayed until longer-term support improves, which again is principally achieved through success at actions that gain approval and show positive benefit to the community. And if your group is not willing to see an impactful and winnable campaign through to a successful implementation or a health-promoting compromise, the group should re-examine its mission, vision, and agenda before proceeding.
While the idea of replacing political leaders (or operational leaders resisting implementation once an action is approved) for failing to support simple, popular, and obviously beneficial actions may seem extreme, but this is in fact often the best possible time to do this. If an action is so clear-cut and beneficial to the community, and it is still opposed by a leader, there is an excellent chance it can be used to win popular support to replace or weaken the leader. After all, the leader’s resistance to health actions is likely only to increase with the complexity and progressivity of future actions, but in such cases widespread poplar support may be harder to mobilize and replacement of the leader thus made more difficult.
Always, in choosing and implementing health campaigns, choose wisely and persevere deliberately, with both short-term momentum for your group and the long-term health of your community in mind. And always approach others with openness and respect, clear reasoning from essential facts, and receptivity to alternative ideas. In this way, you will gain added power for your efforts, through mastery of both the information and process surrounding each health action.
Consider that when others disagree with you, they may be right and your group has missed essential considerations (a risk that is greatly reduced through vetting and open exchanges of ideas). Or other may simply see the issue from a lower state of personal or community health, states that you seek to change and that they may not be able yet to see beyond. In all cases, patience, transparency, gentle purposefulness, and respect will prove essential to helping others understand and support (and perhaps improve) your Community Vision and Community Health Agenda.