This chapter draws on a survey on community action in health in the Basque country to outline the extent of co‑ordination between actors and evaluation of initiatives. It focusses on strategies to motivate participants and engage them as well as on information sharing, efforts to monitor the impact and implementation challenges.
Community Action to Strengthen Health Equity in the Spanish Basque Country
Abstract
To gain a deeper understanding of the tools used to implement community action in the Basque Country and the co‑ordination mechanism in place connecting the various stakeholders involved in community action, the OECD community action survey was widely distributed among different stakeholders involved in community action in the Basque Country (for more details on the survey and its distribution as well as the respondents refer to Chapter 6).
The results of the survey are summarised in this chapter, starting with an overview over the array of tools utilised in implementing community action initiatives, encompassing guides (Section 7.1) and strategies employed to motivate participant involvement (Section 7.2). It also highlights collaboration of stakeholders with private companies or universities for various aspects of community action (Section 7.3). Subsequently, the chapter focusses on the depths of co‑ordination of stakeholders involved in community action (Section 7.3) and the extent to which information is shared between actors (Section 7.5), followed by details on ongoing efforts to monitor and evaluate initiatives (Section 7.6). The final section of this chapter outlines the primary challenges respondents encounter when implementing community action initiatives on the ground and their suggestions for strengthening community action across the Basque Country (Section 7.7).
Guides with instructions on how to best implement community action initiatives may present a first tool to support stakeholders in the implementation of community action initiatives on the ground. While there are numerous such guides available, both internationally and in the Basque Country (see Chapter 3, Section 3.2.1) the OECD community action survey focussed on the use of four guides produced in the Basque Country, among which two are co-written by the DPHA within the DHBC.
The “blue” guide, co-written by the DPHA and Osakidetza in 2016, titled Methodologic guide to address health from a community perspective (for a more detailed description of this guide refer to Chapter 2, Sections 2.2.2 and Chapter 3, Section 3.2.1) is the most commonly known among the four guides, with more than 75% of survey respondents having heard about it. However, only 53% report to have read it and less than 25% report to use it actively (see Figure 7.1, Panel A). Not surprisingly, the main users are from within the DPHA and Osakidetza, while the guide is least known among municipalities (see Figure 7.1, Panel B). A similar pattern is observed for the second guide co-written by the DHBC and other stakeholders in 2020, titled Guide for Participation Generating Well-being and Health (iLab, 2020[1]) (see Chapter 2, Section 2.2.2 and Chapter 3, Section 3.2.1). Overall usage of this guide is even lower at 12%, with 43% of the respondents unaware of the guide.
The strategy for community action proposed by Marchioni and Morín Ramírez (2016[2]) is used slightly more often, with almost 17% using it actively. Contrary to the other guides, the model by Marchioni and Morín Ramírez is most utilised by respondents from the third sector and municipal governments, and primarily by respondents working in Bizkaia. Lastly, the strategy by the provincial Government of Gipuzkoa (Diputación Foral de Gipuzkoa, 2022[3]) to promote community action in their province is the least known and used, with almost 75% reporting no knowledge of it. The few active users mainly stem from provincial governments.
Share of respondents who report to use any of the four guides actively (Panel A), and percentage of respondents who responded to a given statement about their use and knowledge of a guide called Methodologic guide to address health from a community perspective co-written by the DPHA (Panel B), 2024
Note: The figure in Panel A shows the share of respondents who report to use a certain guide actively. The blue guide refers to Methodologic guide to address health from a community perspective co-written by the DPHA in 2016, the Marchioni strategy refers to Marchioni and Morín Ramírez (2016[2]), the yellow guide refers the Guide for Participation Generating Well-being and Health (iLab, 2020[1]) and the Gipuzkoa strategy refers to Diputación Foral de Gipuzkoa (2022[3]). Panel B shows the percentage of respondents who replied with a certain answer in the legend about their use and knowledge of the guide for community action called Methodologic guide to address health from a community perspective co-written by the DPHA in 2016. DHBC is the abbreviation of Department of Health of the Basque Country and DPHA is the Directorate of Public Health and Addictions within the DHBC. The question was answered by 181 respondents, Panel B excludes 15 responses from institutions excluded in the panel.
Source: Data collected via the OECD community action survey (see Chapter 6, Section 6.1).
The above‑mentioned guides contain specific instructions and tools for successful community action. Even if the respondents are not aware of the guides or do not actively use them, they might still use some of the methods and tools proposed in those guides. The OECD community action survey therefore asked about the respondents’ use of a set of nine tools to motivate participants to join community action initiatives.
Overall, the most popular strategies to motivate prospective participants to join community action initiatives include advertising on the organisation’s website, reaching out to local associations, posting advertisements in local health centres, and asking health professionals to advertise among patients (Figure 7.2). The latter two are particularly popular among respondents from Osakidetza and the DPHA. Some respondents additionally mention to advertise via local TV or radio stations or via existing WhatsApp groups (covered under “Other” in Figure 7.2).
Number of times a tool is mentioned among the top 3 of tools used to advertise community action initiatives, 2024
Note: The underlying question asked respondents to pick the tools/methods used to promote community action initiatives (among all options on the vertical axis) and to rank the ones chosen by frequency of use. The figure plots the number of times a tool was chosen by respondents in the top 3 of tools used. 152 respondents replied to this question.
Source: Data collected via the OECD community action survey (see Chapter 6, Section 6.1).
The guides for community action also emphasise the importance of involving members from disadvantaged groups in community action initiatives. Figure 7.3 shows that respondents to that end focus on specifically inviting members of such groups, often by taking advantage of pre‑existing connections between social services and members of excluded groups. They further often mention thoughtful communication, with using non-technical and inclusive language and valuing empathy and respect as an important tool to reach disadvantaged groups. Monetary and non-monetary compensation (such as offering food or drinks during or after meetings) are rarely used.
In addition to encouraging initial participation, sustaining continued participation often poses challenges for community action initiatives. Respondents report to mainly rely on two tools to motivate participants to remain engaged: (1) ensuring that meeting times and locations are convenient for all participants, and (2) establishing a meeting atmosphere conducive to all participants feeling comfortable expressing their opinion freely (see Figure 7.4). Similarly to initial participation, monetary and non-monetary compensation are rarely used to motivate continued engagement.
Number of times a tool is mentioned among the top 3 of tool used to advertise community action initiatives among disadvantaged groups, 2024
Note: The underlying question asks respondents to choose the tools used among all options on the vertical axis to reach and include individuals belonging to one of the following groups for community action initiatives: immigrants, isolated individuals, ethnic minorities, and individuals with low socio‑economic status. Respondents are further asked to rank the chosen tools by frequency of use. The figure plots the number of times a tool was chosen by respondents in the top 3 of tools used. 151 respondents replied to this question. Non-monetary compensation refers to offering food or drinks during or after meetings.
Source: Data collected via the OECD community action survey (see Chapter 6, Section 6.1).
Number of times a tool used to motivate continued participation in community action initiatives is mentioned among top 3 tools, 2024
Note: The underlying question asks respondents to choose the tools used among all options on the vertical axis to motivate participants to continuously join community action initiatives. Respondents are further asked to rank the chosen tools by frequency of use. The figure plots the number of times a tool was chosen by respondents in the top 3 of tools used. 150 respondents replied to this question. Non-monetary compensation, for example refers to offering food or drinks during or after meetings.
Source: Data collected via the OECD community action survey (see Chapter 6, Section 6.1).
Many definitions and theories of community action distinguish various levels of involvement of the community in community action (see Chapter 1, Section 1.1). The OECD community action survey asked respondents to classify their ongoing initiatives into consult, co-design, and co-management, with brief descriptions of each category. Consult is described as initiatives where the community participates in the identification of problems to be addressed, co-design is described as initiatives where the community participates in the design of appropriate initiatives and co-management are initiatives where the community participates in the implementation of the chosen initiative, such that the initiative will ultimately be managed by the community.
Respondents classified 31% of their ongoing initiatives into the consult category, indicating that a third of their initiatives only involves the community to consult on specific issues. 21% of ongoing initiatives are classified as co-design and hence additionally involve the community in designing a specific intervention. Finally, another 20% are classified as co-management and involve the community as an equal partner throughout the process. While most institutions align with this distribution across categories, Osakidetza stands out with a higher share of initiatives in the consult category and only few initiatives in the other two categories.
There are two reasons that the above reported numbers do not sum up to 100%. One, respondents were asked three separate questions regarding the share of their initiatives falling into the categories of consult, co-design, and co-manage. Each question provided predefined percentage ranges as answer options. The survey did not enforce that respondents’ answers across these three questions would collectively sum to 100% due to the nature of the percentage range options.1 Two, to calculate averages across respondents, the midpoint percentage value was considered for each answer range. For instance, selecting the range option of 10%‑25% would be considered as 17.5% when computing overall averages. If respondents tended to select numbers towards the higher end of the percentage range, using these midpoint values would result in lower aggregate percentages that do not necessarily total 100%.
The OECD community action survey also inquired about respondents’ collaboration with both private companies and universities. Municipal governments are the primary stakeholders working with private companies for community action, with almost 80% of municipalities having hired a private company for at least some tasks related to community action (see Figure 7.5). These companies are typically hired to evaluate the needs of a community and to design appropriate initiatives. Among the other institutions, employing private companies for community action is uncommon, with not even 20% of respondents from third sector, pharmacies, Osakidetza or DPHA reporting to hire such services.
Collaboration with universities is also concentrated within one institution, although the pattern is less strong compared to hiring private companies. About 75% of respondents from the third sector report to collaborate with a university on community action initiatives (see Figure 7.5). They mainly co‑operate on designing initiatives and monitoring and evaluating them. Osakidetza and municipal governments also collaborate with universities to some extent, with around 35% of respondents from either institution reporting at least one collaboration. The DPHA collaborates the least with universities, with only 20% of respondents mentioning such co‑operation.
Share of respondents who hire private companies for community action, by institution (horizontal axis) and task the company is hired for (legend) (Panel A), and share of respondents who collaborate with universities for community action, by institution (horizontal axis) and task of collaboration (legend) (Panel B), 2024
Note: The figure Panel A shows the share of respondents by institution who hire private companies for community action. The shades of blue within a bar indicate the tasks the private companies are hired for. Panel B shows the share who collaborate with a university for community action. The shades of blue indicate the task on which the institutions collaborate with universities on. DPHA is the Directorate of Public Health and Addictions within the Department of Health of the Basque Country. 173 respondents answered this question. The figure excludes 14 responses from institutions not shown in the figure.
Source: Data collected via the OECD community action survey (see Chapter 6, Section 6.1).
As suggested by the guides, effective co‑ordination and information sharing among the various actors in community action can have several benefits for community action. It may foster collaboration across institutions, eliminate duplication, and improve initiatives by learning from others’ mistakes. As seen in Chapter 6, Section 6.2, most actors and institutions are part of a network, which is one form of co‑ordination.
Apart from co‑ordinating specific initiatives via community action networks, information sharing on other ongoing initiatives or exchange on best practices for community action with other actors is not common in the Basque Country. Such co‑ordination is mainly done within the institution, but to a much lesser extent with other stakeholders (see Figure 7.6). Although some respondents share information or exchange on best practices with municipal governments, very few report to share with other levels of government, and almost no one interacts with other countries to exchange information or best practices.
Respondents furthermore only share information on an ad hoc basis when a need arises. Except for Osakidetza, most respondents report to not have regular meetings or events to share information and exchange on best practices.
These findings support the conclusions reached in Chapter 5, Section 5.1 on how community action in the Basque Country could benefit significantly from the introduction of co‑ordination and information sharing protocols and infrastructure.
Number of times each institution with which a respondent shares general information on community action (Panel A) and with which respondent exchanges on best practices for community action (Panel B) is mentioned in top 3, 2024
Note: The underlying question asks respondents to choose among the options on the horizontal axis to denote with whom they either share general information on community action (Panel A) or with whom the exchange on best practices (Panel B). In both cases, respondents were asked to rank the options chosen by frequency of use. The figure shows the number of times an option was chosen among the top 3. 137 respondents replied to the questions underlying Panel A and Panel B.
Source: Data collected via the OECD community action survey (see Chapter 6, Section 6.1).
The OECD community action survey inquired about respondents’ monitoring and evaluation practices. To ensure clarity, the survey provided brief explanations of the concepts of both monitoring and evaluation, followed by a set of actions that constitute a comprehensive monitoring and evaluation strategy. Respondents were then prompted to indicate which of these actions they routinely implement for their community action initiatives.
Among respondents from both the third sector and municipal governments, nearly all indicated that their organisations engage in some form of monitoring (Figure 7.7, Panel A). The share is lower for Osakidetza, and the DPHA, with one‑third (30‑35%) of those organisations not conducting any monitoring. Comparing the kind of monitoring activities (Figure 7.7, Panel B) shows that respondents do not consistently implement the majority of monitoring activities. Even within the third sector, only 43% of respondents report performing at least five out of the seven specified monitoring activities, with this figure dropping to as low as 4% among Osakidetza respondents.
Respondents to the OECD community action survey cited several challenges hindering rigorous monitoring efforts. A notable 58% identified a general shortage of personnel, while insufficient financial resources were cited by 37% of respondents as a significant obstacle. The DPHA, and Osakidetza also identified a lack of political will as a hindrance to monitoring (39% of respondents from these two institutions), while lack of personnel trained in monitoring was frequently mentioned as a challenge among DPHA respondents.
Share of respondents who do at least some monitoring, by institution (Panel A), and share of respondents who perform a certain monitoring action specified on the horizontal axis (Panel B), 2024
Note: Panel A shows the share of respondents from each institution who report that their organisation does at least some monitoring. Panel B shows the share of respondents who confirm that their organisation performs a given monitoring action on the horizontal axis. Both figures are based on 142 responses. DPHA is the abbreviation of Directorate of Public Health and Addictions within the Department of Health of the Basque Country.
Source: Data collected via the OECD community action survey (see Chapter 6, Section 6.1).
In line with the results on monitoring, the third sector is most active in evaluating (see Figure 7.8). Almost 60% of third sector respondents report to evaluate all their initiatives, and another 27% evaluate selected initiatives. The share of respondents who do not evaluate at all is largest among Osakidetza, with 35% reporting to not evaluate any of their initiatives.
Similar to monitoring, the biggest obstacle to evaluation is a general lack of staff (55% of respondents), as well as lack of staff trained to design and execute evaluations (37% and 29% of respondents, respectively). Lack of financial resources is another challenge, with 37% reporting insufficient funds for evaluations, and Osakidetza, the DPHA and pharmacies are again missing political will to implement evaluations (37% of respondents from these three institutions compared to 21% for the remaining institutions).
The last section of the OECD community action survey inquired about the major challenges to community action that respondents experience, and potential avenues to improve community action in the Basque Country.
Most respondents see the lack of a global strategy as the main obstacle to community action in the Basque Country, followed by low awareness about community action and lack of financial resources (Figure 7.9). Lack of clear responsibilities is almost as important as lack of financial resources, but lack of co‑ordination both within and across organisations as well as lack of political leadership are mentioned less often. As with obstacles to rigorous monitoring and evaluation, lack of personnel is also perceived as a more general issue for community action.
Share of respondents that do not evaluate at all, that evaluated selected initiatives, and that evaluate all their initiatives, by institution, 2024
Note: The figure shows the share of respondents who reported to do no evaluation in dark green, some selected evaluation in medium green and those who report to always evaluate are marked in light green. The question underlying this figure was answered by 142 respondents. DPHA is the Directorate of Public Health and Addictions within the Department of Health of the Basque Country.
Source: Data collected via the OECD community action survey (see Chapter 6, Section 6.1).
Number of times a challenge was mentioned under the top 3 global challenges in community action, 2024
Note: The underlying question asked respondents to choose the perceived global challenges to community action in the Basque Country among all the options on the x-axis. Respondents were then asked to rank the chosen challenges by severity. The figure shows number of times a given challenge was mentioned under the top 3 global challenges to community action in the Basque Country. 136 respondents replied to this question. Lack of awareness refers to awareness about community action.
Source: Data collected via the OECD community action survey (see Chapter 6, Section 6.1).
When it comes to implementing individual initiatives, respondents’ main perceived obstacles are a limited availability and commitment of the involved individuals, followed by difficulties to motivate the community to participate (Figure 7.10). Keeping the community interested in joining is also the biggest concern mentioned by participants when asked about challenges to keeping initiatives running. A further challenge to setting up successful initiatives is the co‑ordination among participants on finding meeting times and places that suit everyone.
To improve community action in the Basque Country, most respondents agree that co‑ordination not only between the different institutions but also with the local level needs to be improved (Figure 7.11). This finding supports the conclusions reached in Chapter 5 of this report on how a co‑ordination strategy linking efforts of different government bodies and levels is key to strengthening community action in the Basque Country. Relatedly, respondents hope for the establishment of clear responsibilities between the different sectors and institutions, again supporting the recommendations in Chapter 3 and in particular in Section 3.3.3. Further wished for are opportunities to better train staff in community action and a more secure financial backing of community action initiatives.
Number of times a challenge was mentioned by respondents among the top 3 challenges faced when implementing community action initiatives, 2024
Note: The underlying question asked respondents to select the challenges (listed on the x-axis) they face when implementing individual community action initiatives. Among those selected, respondents are asked to rank them by severity. The figure plots the number of times a given challenge was mentioned among the top 3 challenges when implementing community action initiatives. 137 respondents replied to this question. Co‑ordination difficulties refer to finding adequate meeting times, etc.
Source: Data collected via the OECD community action survey (see Chapter 6, Section 6.1).
Number of times an action is chosen among the top 3 actions to improve community action in the Basque Country, 2024
Note: The underlying question asks respondents to select the best actions to take to improve community action in the Basque Country among the options on the x-axis. Respondents are further asked to rank the selected actions by importance. The figure plots the number of times a given action was selected as one of the top 3 actions to take to improve community action in the Basque Country. 136 respondents replied to this question.
Source: Data collected via the OECD community action survey (see Chapter 6, Section 6.1).
References
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[1] iLab (2020), Guía para una participación generadora de bienestar y salud, https://www.ogp.euskadi.eus/contenidos/proyecto/ogp_compromiso_3/es_def/adjuntos/Guia_ILAB.pdf.
[2] Marchioni, M. and L. Morín Ramírez (2016), La intervención comunitaria, https://comunidad.semfyc.es/wp-content/uploads/Comunidad-_-La-intervenci%C3%B3n-comunitaria.pdf (accessed on 16 April 2024).
← 1. This condition was not introduced in the survey due to the answer options in the form of percentage ranges which made it impossible to sum over the percentages chosen in the three questions.