How can community health programmes build enabling environments for transformative communication?: Experiences from India and South Africa

Whilst much research has examined how to empower poor community members to identify the social roots of health problems and articulate demands for health-enabling living conditions, less is known about how to create receptive social environments where the powerful are likely to heed the voices of the poor. This paper seeks to characterise the social environments in which community-led health programmes are most likely to facilitate effective and sustainable health improvements, using three dimensions to characterise social contexts: material, symbolic and relational . We distinguish between technical communication (the transfer of health-related knowledge and skills from experts to communities) and transformative communication (a more politicised process, where marginalised groups develop critical understandings of the social roots of their ill-health, and the confidence and capacity to tackle these). Drawing on secondary sources, we compare two well-documented case studies of HIV/AIDS management projects. Both sought to use technical communication about HIV/AIDS as a springboard for developing transformative communication skills amongst marginalised women. The Entabeni Project in South Africa sought to empower impoverished women to deliver home-based nursing to people with AIDS. Whilst it performed a vital short-term welfare function, it did not achieve its goals of leadership by local participants and long-term sustainability. By contrast, the Sonagachi Project in India, which started as an HIV-prevention programme targeting female sex workers, has achieved both these outcomes. We examine the way in which pre-existing social contexts in West Bengal and rural KwaZulu-Natal impacted on the possibility of effective mobilisation of excluded women in each case. We also highlight the strategies through which Sonagachi, but not Entabeni, was able to alter aspects of the material, symbolic and relational contexts of participants’ communities in ways that opened up significant opportunities for project participants to articulate and assert their needs, and motivated powerful actors and groups to heed these demands