SUSAN HUBER
President of Ascension Global Mission and Senior Vice President of Sponsorship for Ascension

The importance of collaboration has always been foundational to Ascension's health care work. The historic sponsoring organizations of Ascension were founded between 400 and 800 years ago. All have collaboration embedded in either their charisms or in their mission or value statements. So, it is no surprise that when Ascension Global Mission began in 2011 with seed capital from historic sponsors and Ascension, its vision was to "engage in international efforts to improve the health and living status for poor and vulnerable populations in low resource countries through 'collaborating' with local and global communities, including sponsoring congregations and other religious communities, to foster long-term, sustainable change." Collaboration was not just a good idea — it was an expectation.

Ascension's sponsors also understood that defining what constituted care — and how to sustain it — was the work of the local population. Ascension Global Mission sought to support the local vision to set priorities and address needs.

True collaboration takes time, patience and resources. It takes time to develop trusted relationships with local leaders and partners necessary to establish the solid foundation to create and ensure systemic change. In an environment that requires measurable outcomes, it takes patience to defer these metrics while continuing to commit the resources required to sustain the building of trusted relationships.

In 2011, Ascension Global Mission began exploring how it might contribute to improving the health of the most vulnerable in Guatemala. The initial years were spent listening, learning and exploring relationships with potential partners. Our relationships evolved with a group of faith-based partners — the Daughters of Charity of St. Vincent de Paul, Province of Central America; the Episcopal Conference of Guatemala's Pastoral Care for Early Childhood Development; and the Barbara Ford Peacebuilding Center, an organization founded by the Sisters of Charity of New York.

These partners critically reflected how traditional efforts of development aid create a paternalistic relationship where 1) communities become reliant on the expertise and resources of outsiders; 2) results are often not sustained; and 3) community members are not left with the skills and perspective to address other development issues beyond the principal project objective. Through this exploration and dialogue with our partners, we came to understand that supporting charitable projects for vulnerable communities had to go "beyond" well-meaning solutions to have the desired sustainable impact. We set forth to develop a new approach to enable and empower participating communities through self-sustaining collaborative action.

BUILDING A COLLABORATIVE CONCEPT
In 2016, our Guatemalan partners, known as Alianza, set out on a deliberate journey to discover how to most effectively "walk with" and support people living in poverty in order to identify and take action on a range of issues that impacted their health and well-being. Now referred to as "The Method for Collaborative Governance," this approach has been implemented in 35 communities, impacting over 26,000 people. Through creating a school for community facilitators — a train-the-trainer concept that builds the capacity of select community members to foster good governance, plus awareness and interest in integral health within their own community — this method is poised to be adopted and expanded in other communities globally.

What is the Method for Collaborative Governance?
The Method for Collaborative Governance is a grassroots approach to activate and strengthen community governance, enabling groups to come together, identify priorities and take action on what matters most to them. This approach focuses on generating the conditions for effective collaboration among community, municipal and institutional leaders so they can build and promote processes for sustainable impact.

Ascension Global Mission, through its Alianza partners, employed community facilitators trained to ask effective questions to stimulate discussion and highlight and enable local knowledge and expertise. Community leaders are encouraged to debate, analyze and make decisions. Although a seemingly simple concept, asking the right questions at the opportune moment requires listening carefully, understanding context and community dynamics, and framing the question appropriately to ensure community authenticity. It also requires mutual trust.

Phases of Community Work
Implementation of the Method for Collaborative Governance at the community level has five phases:

Phase One — Establish the Relationship: The facilitator connects with the community leader(s), gains an understanding of the community, shares the concept and approach of working with the community, and ultimately "asks permission" to engage with the community. This requires regular meetings between facilitators and a wide range of community leaders to build understanding and trust. It also helps to ensure representation and inclusion of often overlooked silent community voices. Below are some questions that the facilitator should consider asking the community leader(s):

• Who should be involved?
• Who/what groups are not represented in these discussions?
• May we work with you in your efforts?

Phase Two — Discover Problems: Community leaders share their community's achievements, advances, difficulties and local challenges. What emerges from the following questions forms the basis of an agenda of community issues important to local leaders and their communities: 

• What challenges impact the community most?
• What is already being addressed that could be built upon?

Phase Three — Prioritize and Decide Actions: Community leaders set priorities and plan action, leading their communities to resolve issues locally, without external support, by examining additional questions:

• What criteria will determine projects to be evaluated?
• What is necessary to secure community "buy-in" and mobilize support?

Phase Four — Solve Problems: Community leaders proactively promote and implement their action plan, which includes obtaining and managing any external support identified by asking:

• What can we do ourselves?
• What reputable external organizations can lend support and who has the relationship with the external organization(s)?
• How do we ensure that the external organization addresses our expectations versus their desires?

Phase Five — Achieve Self-Sustaining Collaborative Governance: Local communities have established collaborative governance as a norm and function entirely without the facilitator.

In our experience in Guatemala, the role of the Alianza facilitators was to ask the appropriate, probing questions to subtly guide the community and its evolving leadership through the first three phases. They then deliberately began to step away in phase four in preparation for full transition to the community in phase five. It is important to note that this is not a linear process. For example, communities could progress to phase three and recognize that not all voices were at the table (for example, women) or have community leadership roles change, which would require them to step back to the processes in an earlier phase.

RESULTS
Improved Governance
Strengthening community governance is a critical component of supporting people to be agents of their own destiny. It involves leading the improvements they want to see rather than becoming voiceless recipients of charitable aid and solutions from well-intentioned international organizations. Through our findings, stronger community governance prompted the following outcomes:

• Increased participation and engagement of women in community leadership forums that helped raise awareness of challenges impacting children's health and generated support for prioritizing efforts to overcome those issues.
• Created regular opportunities for a variety of community leaders to come together to identify and discuss issues. This enabled communities to focus their efforts, mobilize community support and advocate with government agencies for specific projects.
• Fostered in-depth analysis of the problems that community members identified, which enabled leaders to devise more holistic, creative solutions and lead the implementation of those solutions.

 

Tangible Community Projects and Initiatives
Working with Alianza, community leaders identified and analyzed the most important issues to health and well-being from their perspective and determined actions to take, mobilizing resources within their community and, when needed and possible, through support from external entities. Issues addressed included:

• Trash management: Trash is a significant problem in most rural communities as they do not have access to regular trash removal services. Several communities identified this as an issue impacting their community health and mobilized to address it. As a result, clean-up campaigns and community policies to reduce waste were initiated. Neighboring communities, who also prioritized trash management as a major issue, collaborated to develop a coordinated trash collection system.
• Wastewater management: For many communities, wastewater runs in streets and open ditches, eroding the soil, deteriorating streets and causing health hazards. Many rural families use basic pit latrines, which are hard to keep sanitary especially during the rainy season. Solutions to address the problem take time and resources. Alianza supported communities to resolve all or part of their drainage systems through connecting them with nongovernmental organizations and/or government agencies to explore solutions, mobilize resources and implement construction.
• Access to health services: Communities identified lack of consistent access to health services as an impediment to physical wellness, particularly for mothers and children. One community advocated with local health authorities to reinstate monthly ambulatory services. Another devised a strategy to pay for essential operating costs. Furthermore, another partnered with local health authorities to coordinate monitoring and care for high-risk children.

 

LASTING IMPACT OF OUR EFFORTS
Since Ascension Global Mission was founded, just under $3 million has been invested in this journey. Our efforts helped establish a Catholic-led collaborative effort focused on empowering communities to lead their own sustainable health improvements, capable of expanding to more communities throughout the country.

This work took time, patience and resources. It was not without its challenges and setbacks. But it achieved what we set out to do: collaborate with others to enable systemic change. The Method for Collaborative Governance builds local leaders' competence and capabilities to develop and execute their community's development agenda, prioritizing issues that impact health and children. It is designed to build capacity and empower leaders to continue to proactively drive improvements in their community, beyond the promise of any specific external aid project. As noted earlier, a key component to this method is the school of community facilitators.

Alianza members are working to integrate the learning and approach into their own organizations, as well as explore how to engage other communities. Although still in its infancy, this method is positioned to be adopted and expanded to generate positive systemic change for many years.

SUSAN HUBER is president of Ascension Global Mission and senior vice president of Sponsorship for Ascension in St. Louis.

QUESTIONS FOR DISCUSSION Susan Huber, president of Ascension Global Mission and senior vice president of Sponsorship for Ascension, details the deep thinking that went into creating the Method for Collaborative Governance. Working with partners at Alianza, those working in global health determined the right questions to ask and ways to collaborate to enable local knowledge and expertise in the communities where Ascension works. What aspects of this approach do you already use in your global health response? Does your organization allow you the time and resources to listen and build trust before measuring metrics and focusing on results? Is there a good way to make the case when more time or support is needed? One question highlighted in this article is: May we work with you in your efforts? Take a moment and think about the collaborative approach embedded in that question. How do you ask others in international work to partner with your organization? Have you had occasions where stated needs didn't integrate well with what the organization anticipated? How did you resolve it? What features of the Method for Collaborative Governance could be used in other community health initiatives your system is engaged in? How might a similar collaborative method be used in communities to address social determinants of health?