CONTEXT: The Massachusetts (MA) local public health system is highly decentralized. All 351 municipalities autonomously manage local public health infrastructure and budget, resulting in service delivery disparities. The MA Department of Public Health (MDPH) recognizes that achieving equitable access to public health services requires systems change, and successful systems change demands active participation and input from partners at all levels. OBJECTIVES: To collaboratively establish the first Performance Standards (PS) with and for MA local public health to reduce inequities in public health system delivery. DESIGN: Partner engagement and the Framework for Applying Qualitative Methods in Health Policy and Systems Research guided PS establishment. Relevant standards from MA laws were compiled and organized using document and thematic content analyses. Partner elicitations guided edits for finalizing PS. SETTING: In 2021-2023, MDPH facilitated statewide partner collaboration to establish PS. PARTICIPANTS: Six key MA public health organizations, representatives from 4 state agencies, and widespread MA local public health. INTERVENTION: Targeted engagement with internal partners enabled drafting PS. Widespread engagement with external partners elicited open comments to improve and finalize PS. MAIN OUTCOME MEASURES: MDPH and partners collaboratively formalized PS after analyzing 283 comments and 66 edits. RESULTS: Through active collaboration with partners, MA formalized the first official PS for local public health, released in October 2023. PS comprise 5 subjects, including 87 standards written into MA legislation across 4 subjects (environmental health, tobacco control, disease control and prevention, administration), plus recommended workforce standards. PS set minimum expectations for local public health credentialing and support consistent public health service delivery. CONCLUSIONS: PS are a steppingstone toward MA public health systems change. Collaboration is critical for partner buy-in, to establish and implement PS using shared resources structures. Effective PS implementation, synergistic with other efforts, will reduce disparities in local public health services and delivery and provide MA residents with more equitable access to public health services.
The decentralization of Emergency Medical Services (EMS) to local administrative organizations is a critical policy initiative in Thailand aimed at enhancing service responsiveness and community participation. This study applied a prospective Health Impact Assessment (HIA) to identify positive and negative health impacts of EMS decentralization in Chonburi Province and develop evidence-based policy recommendations to guide the transition from the Ministry of Public Health to local governance. A mixed-methods approach was designed based on the six-step HIA framework. The study involved 562 participants, including EMS providers, recipients, and policymakers. Qualitative participants were selected through purposive sampling for interviews and focus groups, and quantitative participants through stratified random sampling for surveys. Qualitative data were thematically analyzed, and quantitative data were analyzed descriptively. Findings revealed both positive and negative impacts across four pre-hospital care activity domains (dispatch, incident response, referral, and administrative management) and four dimensions of well-being (physical, mental, social, and spiritual). Positive impacts included improved responsiveness, collaboration, and staff motivation, while negative impacts involved personnel shortages, communication gaps, and limited budgets. The derived policy recommendations emphasize structured workforce planning, upgraded communication systems, sustainable financing, and participatory monitoring to strengthen decentralized EMS. The use of HIA provided a systematic and participatory process that translated empirical evidence into actionable policy guidance for health service decentralization in Thailand and similar contexts.
Professor Andharia has over 26 years of experience in the field of community organization and social development. Her areas of work focus on gender issues, environmental concerns, social planning and participatory development, addressing diverse forms of marginalization and vulnerability. She has been involved in policy work and has had a long association with grassroots organizations. She has been teaching at the Tata Institute of Social Sciences (TISS) for over two decades and was Head, Department of Urban and Rural Community Development before moving on as Chairperson of the newly created Centre for Disaster Management. Community organization (CO) has come to acquire a distinct meaning in India. This special issue reflects upon the nature of intervention of community workers and forces of transformation both in the lives of ordinary people, especially the poor and the marginalized, and within the sphere of knowledge related to community studies, across diverse institutions and socio-political contexts. The selection of articles in the issue captures the theoretical refinement of CO and also represents challenges that CO practice confronts at the practical level in the contemporary Indian scenario. The history of India as a nation is replete with organizing, asserting, demanding and fighting for rights. It is the collective assertion and courage of citizens that are often celebrated on 15 August â the date in 1947 when India got her independence. A relatively young nation, India covering an area of 3,300,000 km2 and housing a large diversity of ethnic groups1 is respected as one of the largest democracies in the world. CO was introduced as a method of social work in the 1950s in several western countries, and it was also during this period that the Department of Urban and Rural Community Development (URCD) was established in the first school of Social Work in India, generating several scholars and practitioners espousing diverse perspectives and ideologies. By 1980s the term âCommunity Developmentâ was generally regarded with disdain due to the failure of the official Community Development Programme, launched by the Government in the 1950s. In India the term âCommunity Organizationâ on the other hand was regarded as far more progressive and received an impetus through the mid-1970s up until early 1990s. In 1975â1977 the country experienced political upheaval when a state of Emergency was declared suspending official democracy. This simultaneously gave rise to a large number of protests with a democratic fervour and specifically in the form of mass-based movements and voluntary organizations. It also saw a critique of social work positioned largely as an apolitical enterprise. The failure of community development programmes to impact the poverty levels or people excluded from health, education, housing, sanitation and infrastructure services forced social workers and community organizers to re-examine its excessive emphasis on local development issues. They began to recast their work to include structural factors that shape local realities. The expanding critique of social work influenced CO teachers who redefined and reshaped CO to align with, contribute to and borrow from literature on diverse forms of organizing â social movements, trade unionism and mass-based people's organization and self-help groups (SHGs). Organizing communities against atrocities and against forms of dominance is evident in almost all parts of India and is not restricted to a particular discipline. In fact, sensitive social workers draw on the history of organizing within a region or of specific communities, metaphorically invoking historical events to reach out to the masses. A generation of teachers and activists from 1980s onwards who began to associate themselves with mass-based struggles, discovered different strategies and new allies and questioned conventional moorings of western forms of institutionalized social work and its relevance to India. Grass-roots empowerment took precedence over community development and saw greater involvement of community organizers and scholars in issues of exclusion, violation and assertion of rights, discrimination against dalits, tribals and other marginalized groups. (See Figure 1 for an overview of the trajectory of CO and CD in India.) A sharper ideological orientation gave CO a political edge much to the discomfort of certain social work professionals. Historical trajectory of CO and CD in India. Source: Andharia (2007, 103). The changing perspective of CO in particular compelled the social work fraternity to review its curriculum, the choice of field work agencies and the intervention processes with which scholars aligned themselves. Modes of intervention were questioned and revised, tools of analysis underwent a shift and political frameworks were consciously used, in more fundamental ways to shape both the practice and education in CO. Despite the strong imperative to move away from a traditional social work orientation based on a naĂŻve belief of âbridging gapsâ through simple welfare means, the transition within the academia was painstakingly slow. At the end of nearly three decades of debates, most of these changes remain undocumented even as CO confronts fresh challenges in contemporary times. For example, the fact that the economic reform agenda is pursued assiduously by the government, when poverty and inequality levels remain high, exploitation is legitimized by the state and the globalizing forces are moving ahead unabashedly, is all a matter of serious concern to community organizers. Withdrawal of the state from health, education and social security sectors has caused further exclusion and deprivation of the marginalized section. The special issue on CO in India is devoted specifically to locating the challenges of the context and possibilities which community workers in India need to familiarize themselves with and it is hoped that it renews interest in collective action for social transformation in a rapidly globalizing world. A community in some ways is a microcosm of a nation. One would assume that in a democratic nation, all institutions function democratically upholding values of equity with reference to citizens and their collectives. However, in practice, this does not happen and rights have to be asserted and structures are to be negotiated. As a result the understanding of democracy, citizenship and collective action are never static. A community gets mobilized when citizens organize to take a stand and work towards specific demands. Such assertions are fundamental to the empowerment of citizens and such shifts in power balance between people and institutions are fundamental to CO. The broader context for CO practice in India can be discerned from the country's performance on human development indices and the agenda for community practice may be drawn from a critical appreciation of processes that marginalize and alienate large sections of society. India is often called a country of contradictions. For example India prides itself as a nation on the move, a nation that has witnessed, during the last century â a transformation from a colonial, agrarian economy into a modern, industrial, knowledge-based economy. As a parliamentary democratic system, the country is an acknowledged home to people of diverse cultural, faith, ethnic and social identities. The constitution provides for democratic participation of citizens giving them a voice in politics. Popular movements and struggles are credited with ensuring that parliamentary democracy has retained its vitality over the last 60 years of independence. On the other hand, despite the political democracy, the country is faced with economic inequalities, concentration of wealth and regional imbalances that work in favour of exploitative social, political and economic structures. About 70 percent of India's population is rural and agriculture is the backbone of livelihood security system for nearly two-thirds of the population. Farmer's suicides, ethnic tensions created by right-wing Hindutva forces, poverty, malnutrition, disease and deprivation, falling per-capita intake of food grains are often said to reflect the erosion of democratic principles and secular fabric of the nation. The media and the judiciary have played a significant role in highlighting the backwardness and social injustice and inequalities based on caste, class, gender and ethnicity. Besides popular struggles, new social movements led by trade unions, women's organizations, voluntary organizations and committed individuals have responded to the overwhelming poverty, illiteracy displacement, dispossession of land and rising food insecurity. Criticisms about the ability of the development agenda to ensure social inclusion and equality of opportunity for all have sparked vigorous debates about addressing the âdemocratic deficitâ. In India, the Constitution through its amendments has devolved more powers to local bodies, but they are yet to be empowered in full. Their capacity needs to be built and financial powers to be strengthened before we can expect them to adopt best practices in governance. The dalits constitute 16 percent of India's population and the tribals constitute 8 percent. According to government estimates, some 125 districts spread over 12 states, covering more than a quarter of the landmass mostly in the central part of India, is affected by extremist Naxalite activities. A combination of economic and socially oppressive factors is identified as the major cause of rise of Naxalism in India. The next section highlights the democratic deficits' that will enable an appreciation of the Indian social, economic and political fabric which constitutes the context in which community organizer sets an agenda and chooses specific strategies for action. The focus is on food security, education, access to potable water, health care facilities and housing â all of which constitute fundamental rights of every citizen â basic requirements for a life with dignity. During 2007 escalating food prices and vanishing global food reserves added about 75 million to the hunger trap of which nearly 30 million are from India according to a Food and Agriculture Organization Report [2007]. Data from the National Family Health Surveys paint a grim picture. More than one-third of the Indian population lives in sub-human poverty and a recent World Bank estimate put nearly 42 percent as absolutely poor by international standards. More than three-fourths of the population has a daily purchasing power of less than 20 rupees a and nearly the are The Development India out of a of and in the India has to out of Food security a issue in According to Development Report India the hunger the million people, nearly are in India. This it the country housing the largest food population. It in the of Despite years of economic India than nearly and all of of India's rural population or over million people are the food intake of the country's economy is percent with a population of about people, in every are It is that hunger and are in On the other hand, India its into the 12 The wealth of the was to about percent of India's in with less than percent in According to the also as the in India individuals wealth to almost a of the in were the in The Food and Agriculture organization also that percent of the poor in India, as the percent. This the of wealth and are social inequalities in the According to economic be development when it does not into of the of the of the poor in of and as as for health, housing, education and political with economic are and rise in according to be as to people's social and political India's not basic such as to and inequalities are with access to food and before a â it the of between the of 1 and by about one economic does not into hunger More of and health services and action to based on and are and progressive CO practice these issues. to food and and factors as environmental health work and This can be through a of political will and and people's and CO to the and the to work with the of the The of and global factors significant in the analysis of a context and The emphasis is on structural of and The of organizations with National Rural in in or that of in and in all the of work and the of CO. of these are in the articles in this teachers of CO to with these and their of CO move towards a more involvement in ensuring social and political rights, a life with for the The by strong global forces have had a impact on the and rural the is of an to food for and their for a in international prices of the especially who are to their For example, across districts in western nearly have committed over the last of an of poor failure and On an two were to take their lives in the last districts saw two financial several and a for who within the The impact has not been A population that and and in their social and political and to The to education in India are education in government and of and and the of of the school to or local of these constitutes significant areas of intervention by community organizers towards action and to in percent of India's population is percent of India's can the of 75 percent of in India from and the is 42 percent of the received all the and access to education and health care in India. with a rise in prices and the health has for the the in of who is from it and needs to be health and education to ensure that economic development is with and human to is of fundamental for and sanitation have a with health, a human international The by India to access â daily within a â of the World Health of at the end to be as level According to government about percent of the country's have been This is serious as about percent of the from are up or are have and are and major on and are by and The traditional of services has been and are into infrastructure does not the of the government is the need to communities in from and new such as and and take to and This has come about through a of work by rural development by the and may be but it will to a or an environmental and social on the country can put and in The 2007 is a in the history of human for the first the and rural population of the is It is that has new economic and to people who to However, it has also created the of all over the world. According to the of the one in three in are areas people not have access to basic for life with such as water, housing or that from Urban India for 30 percent of the population and its is to rise to about percent by In of a policy and housing in the housing in Indian is on the In 2007 the housing was about million and it is to 26 million by About percent of this to groups. The economy by government especially on agriculture and forced serious the history of organizing and in â the of India the population lives in Community organizing housing rights through the 1980s has been to some but She that political and a for community Her the of CO can be all and education and organizers to with experienced by the the last three decades Indian in participatory democracy, collective by social movements, and organizations a to and reflect on CO. are a of ways of in the with and The and of analysis often the forms of involvement and the choice of strategies In the contemporary of community and CO are rapidly as areas of and practice They draw from political critical and and such as environmental studies, and This nature of CO in India has received in the country has had a and experience in CO and 1950s. The country's political history is replete with movements of people of diverse cultural, social and identities. movements and struggles a strong of a democracy. CO has been through of social action of movements, movements, and is as new social movements women's to a constitute some of the most and of new social movements in human For example, special economic have been up across India with concern for the and that they are over for this The the development of specific areas as and â with infrastructure that would have a capacity and for as a new of at and large they are to be in their and local and The policy and its have serious for groups and communities their and their are largely as a trade capacity development with a to economic A number of community organizers are struggles against across India. The issues to the and of in the of environmental concerns, the to the on rights to organize and and the in which has not been in India. The political of of for development is the most critical of the the largest number of has strong from in and who have themselves into and the which have all a struggles have been in and who were to land by and in the of development. In India, popular movements that the of development is from to led will the imbalances in of economic and power at local and regional levels intervention a political is evident is that over the last three CO in India has experienced through work on health, education, housing, food security or with dalits and has a refinement at the practice level the of collective action and a strong and ideological The of assertions through in the form of trade or in the form of organizations or organization is This is it the that the one are not but collective â a shift towards understanding social issues in or structural with a critical understanding of the power of major development is a of the of CO with other or as community political and studies, community media and of these are in this special issue with The articles and the of CO and the shift and refinement of CO the in social work education in India on in India and the for equality provides an to of the that we in India as a democratic nation. on democratic which is of The for equality a collective form in CO. However, that the of communities impact the of in communities are based on the context and have of communities of caste, and gender needs to on the one hand, within the democratic against of the of and the within community to its of in the exclusion of For example, in a democracy, has an and is on who them and their against equality and gender dignity. at communities on and to the rise of right-wing forces and of of against in the in over a This the of a which to be built on principles of and in a democratic nation. are between two communities which shape both and collective which in often into and Community organizers to despite the of and and for the need to diversity and as fundamental to CO The strategies to and community the organizers to have a understanding of issues, factors and processes and in the It and to that and in community addressing and at and and communities are when CO is committed to human rights and social In this the role of social action the and of food especially on and sections of society. the exclusion faced by marginalized sections India is a food nation and that assertion of rights and community is the The work of Development is by has a with from 75 in of In with other they on education, and and at level food It has also in the specifically on and CO that towards and over local and socio-political institutions through and to the and rise of communities in the of and its The by the drawn between and CO over a â a which has and teaching of CO in India. It in the of the struggles of workers in and a strong for community practice to at issues of work and and for social workers a sharper understanding of of strategies and in grassroots organizing, especially in the of the Indian economy. and the of the for the to in of the of within the government which A long by the rural poor and activists democratic and in the of one of the most progressive in the in It is as a of that the of the citizen with the and voluntary of of and facilities by is greater and is for citizens to the of progressive community organizers are in this area and have been with the India has to In people on part of government to In of of has been from the India has had a strong women's with a of to organizing from which community practice has drawn and in diverse on the of a rising number of and activists have out that in areas have on exploitative created and for to in the and a of women's women's citizenship rights are asserted through by which the agenda of The economic of in out their and women's based on education and empowerment are by that have a financial agenda with focus on rights and social the women's several about By over to the and of work and are generally has been of government such as the Development and the the state is as the for poverty and institutions are of and of The strategies of have of activists across the world. In India, for community an of and at a when is not more and but also more They and values are to be in daily lives by individuals and to and up possibilities and can be to global as a large number of on the â â have been a social by and a young the work by in and for community organizers in a and from a strong in her work with tribals in and districts of are in this The first in rural India and both regarded as economic The on human development in rural India and such as and its education, of education, health care and in development across social groups. The is a of on that are more human than the contemporary political or and have a broader The last a on and in India. CO has political interest distinct from most which largely within of the groups or communities or a both of which have a It to the need or the is in and are through forms of and CO in India is in organizing, on development critical and is based on an analysis of state power and of It is a which all that to power that contribute to the experience of discrimination and CO not at the level of communities but with social structures and with democratic institutions of governance. to activists and a They are or and in different parts of the through are and the system is to the people's organization and their against organizers on or which remain for also their ability to out and education in CO needs to to with these this it is to that community workers have often received their orientation in social they have their of knowledge from a of In their practice, community workers are to specific issues and in of and with a focus on social equality and access to This has a sharper political and CO has in practice has drawn from the context of exclusion, violation of rights, of services and a of issues, of which are in the selection of articles in this special