Boston Healthy Start Initiative: A Case Study of Community Empowerment
Urmi Bhaumik
Boston Healthy Start Initiative
434 Massachusetts Avenue
Boston, MA 02118
Introduction
Many civil society organizations have been instrumental in improving the delivery of health and welfare services, especially in areas with endemic socio-economic problems (Boris, 1998). The Boston Healthy Start Initiative (BHSI), a community driven program serving an identified part of the city of Boston having disproportionately high rates of infant mortality and overall poor health status in general, provides a good example of the functioning of such civil society. Its primary objective is to decrease the prevailing high rates of infant mortality in the project area and to reduce the disparities in maternal and child health status within the city of Boston. BHSI has been promoting this objective by following a strategy of community empowerment for improving delivery and access to services that impact the health of mother and children. In the process it also functioned as a catalyst to strengthen relationships between service providers in the project area who are mostly either government owned, or government funded and the community members who are the recipient of these services.
The much higher infant mortality rates in inner city communities in United States is not only a health problem but also is a consequence of confluence of economic poverty, social isolation, and political neglect. The example provided by BHSI shows that regenerating civil society can play a vital role in addressing many of these problems and lead to lower infant mortality and overall improvement of health status in general. They can do so by providing important spaces where individual citizens learn the vital skill of participation, developing a collective voice in influencing the shape and direction of public policies, and building relationships that bind citizens to a common sense of purpose. However citizens ability to act as a vocal agent in health and welfare relationships depend significantly on the way such organizations are designed. Situations where only the service provider has the authority to make decisions and citizens can only comply or exit have been the bane of many such relationships. BHSI was able to overcome such one-way relationship by developing a forum where all members can participate and alter the way services are delivered to women and children in the project area.
Many a well intentioned program to revitalize civil society either fail to take off or do not succeed in achieving many of the goals set for it. The achievements of BHSI therefore need greater scrutiny to see what worked and what did not and to further examine whether the successful components can be replicated in other projects. This has added importance since the healthy start initiative is being expanded to cover many other geographic areas with high rates of infant mortality.
The achievements of BHSI provide an example of how a city government can spearhead a civil society organization for improving maternal and child health. It shows how a successful partnership was built on the strengths of government (organization, program focus, expertise, and money) that complemented the strengths of a civil society agency (sensitivity to local condition, ability to reach, and organize constituencies). The case study also reveals that despite many favorable circumstances that helped the project to succeed, the implementation of this concept of shared governance between a government supported agency and the community was not always smooth and had to evolve through a number of stages. Important interventions were needed to generate effective participation of residents and to help them resolve differences in the community. However, the BHSI project fully epitomizes how the process finally led to a strengthening the fabric of civil organization among vulnerable sections of population in a city resulting in increased participation of residents in a decision making role.
While trying to understand the areas of success in BHSI it has to be remembered that in Boston the healthy start initiative started not simply as another government conceived program. It evolved from a felt need within the community and the federally funded program only served as a vehicle for concretizing the perceptions within the city regarding the need for starting a community driven program to improve the health status in inner city areas. So one criterion for ensuring the success of such programs may be linked to building up of a groundswell of public opinion in support of the program well before they are initiated. Although a government backed program, the healthy start initiative had enough flexibility to allow local experimentation in the project design and implementation that helped the program to tailor its functioning to the unique situation in Boston. This is a major strength of the program and may help its successful implementation in other areas.
Over a six-year period from 10/01/91 to 09/30/97, the Phase I or the demonstration phase of the Project, BHSI through its active participation with the community in all aspects of the project, from planning, to implementation, and to monitoring, and evaluation, was able to bring about a major transformation in the way health and human services are accessed and utilized in the project area. However the primary achievement of BHSI was in developing a permanent forum of community residents and service providers called the Consortium that enables continuing active participation of all members for improvement of maternal and child health. The Consortium has helped empower a section of community that was unaware of their important role in shaping decisions that affect their health and well being. By developing and continuously promoting collaboration both within the culturally, linguistically, and ethnically diverse community as well as between the community and a multiplicity of service providers, BHSI was able to greatly increase access and utilization of health and human services within the community and also helped to improve the quality of care received by them. This resulted in a significant lowering of the infant mortality and positive changes in numerous other indicators that reflect an improvement in the health and well being of women and children in the project area (Cohen and Mulvey, 1997).
The question that still remains is whether the success of BHSI is a story in isolation or whether it can be replicated among another community trying to improve maternal and child health or in another project setting within the city of Boston. This is of relevance since Boston with its history of proactive movements on health and medical issues may be in a unique position to ensure the success of such a project while the same may not apply in another city or region. However the lessons learned during the implementation of the BHSI project show that despite the seemingly favorable setting, the success of the project was not a foregone conclusion. Many obstacles had to be overcome and numerous changes were needed during the implementation of the project. It is to be expected that implementation of the Healthy Start project in other communities would also have their own share of problems. Some of these may be unique to that setting but it is more than likely that the lessons learned in BHSI may serve as an important guide to preempt many other problems. In fact, BHSI is now playing a major role in mentoring many new sites especially in relation to Consortium building.
It is generally recognized that mobilization of a community on issues concerning maternal and child health may be easier than many other health or social issues. While the problems associated with civil society governance is likely to depend on the nature of the issue being addressed, mobilizing community for civil society organization may still have many common factors irrespective of the issue. The experience gained from BHSI may therefore provide important insight for improving civil society in the city of Boston.
Genesis of BHSI
The prevailing rate of infant mortality in a population is a sensitive indicator of the overall status of public health. Based on this measure US ranks quite poorly when compared with other similarly placed developed countries (National Commission to Prevent Infant Mortality, 1992). Despite a series of efforts both at government and non-government levels including setting up of a number of committees to look into this problem and suggest remedies, the situation had not changed much over the years. In addition, the relative disparities in infant mortality in the population, and the much higher infant mortality rates among some racial, ethnic and linguistic groups are even more troubling (Singh G & Yu S, 1996).
Disparities in infant mortality rates in the city of Boston came to the forefront in discussions during the infant survival summit held in 1990 (Plough and Olafson, 1994). The infant mortality rate of 19.5 deaths per 1000 births among African-American infants were almost three times the infant mortality rate of 7.5 deaths per 1000 births among Caucasian infants. The alarm and frustration among those seeking solutions to infant mortality problem was further heightened by the fact that such racial disparities existed in the backyard of some of the world's most renowned medical institutions. At the same time it was felt that perhaps no other city in the nation had a better opportunity of developing a model to decrease such disparities in infant mortality.
In various analysis and evaluation of projects and programs dealing with infant mortality and public health in general, it has been widely recognized that community participation at all phases of a project is a sine qua non for the success of the project (McKnight, 1985). The summit also reached the general consensus that effective community participation was a must for changing the unsatisfactory state of public health in the problem areas. In subsequent follow up for designing a plan of action to reduce infant mortality it was felt that the Healthy Start initiative being proposed by the U.S. Department of Health and Human Service's Health Resources and Services Administration (HRSA) could serve as an ideal blueprint for this purpose (Trustees of Health and Hospitals, 1991). It afforded enough flexibility to function as a community driven program for reducing infant mortality and promoting maternal and infant health in general (Health Service Resources Administration, 1991). Applications were therefore submitted to HRSA for starting a Healthy Start initiative in the city of Boston.
In 1991 the Boston Healthy Start Initiative came into being when HRSA selected Boston as one of the first 15 sites where the demonstration phase of the Healthy Start was to be launched. The projects were fully funded by HRSA during the initial demonstration phase. However the projects were expected to develop systems for attracting funding from other sources gradually, once the initial financial support provided by HRSA was stopped. The concept of sustainability was thus made an integral part of the project design. The initial demonstration phase of BHSI lasted for six years from 10/01/91 to 09/30/97.
Goals and Objectives
The primary goal of the BHSI was to reduce infant deaths in the project area by 50% by 1997 from the rates prevailing in 1990 (Trustees of Health and Hospitals, 1992). This was to be achieved by a faster decrease in infant mortality in the project area and also by a reduction in the racial, ethnic, and linguistic disparities in infant mortality. A set of eight specific objectives were identified to achieve the above goal. These included: (1) reducing the percentage of low birthweight births in the Project Area; (2) decreasing post-discharge infant mortality in the Project Area; (3) increasing the utilization of health services by women and teens in the Project Area; (4) increasing community participation and leadership in BHSI project planning and management; (5) establishing coordination and linkage among health and human service providers in the Project Area; (6) improving social conditions of pregnant women and community residents in the Project Area; (7) increasing culturally and ethnically appropriate public information and education on infant mortality for residents in the Project Area; and (8) sustaining BHSI funded programs after HRSA funding is terminated. Concurrently long range collateral and short range intermediate objectives were also developed to support the key outcome objectives. Examples of collateral and intermediate objectives included increasing numbers of women receiving adequate prenatal care, access to well women care, and numbers of women who achieve appropriate weight gain during pregnancy.
Structure of BHSI
The BHSI project area is a contiguous group of Boston neighborhoods consisting of census tracts with the highest infant mortality rates in the city. This is an area of great racial, cultural, and linguistic diversity. According to the 1990 census, the total population of the Project Area was 283,167 in 1990 and it accounted for 49.3% of City of Boston residents. Of these 85,441 were women of childbearing age (30.2%). In the Project Area 54% of births were to African-Americans, 20% to Latinos, 16% to Caucasians, and the remainder to Haitians, West Indians, Cape Verdeans, and Asians. The infant mortality rate in the Project Area during 1988-90 was 14.3 per thousand live births.
Right from inception, BHSI was envisaged as a partnership between the Boston Public Health Commission (formerly the Department of Health and Hospitals) and a Consortium of individuals and organizations categorized as consumers, providers, and state and local government. The grantee for BHSI was the Boston Public Health Commission with Boston Medical Center (under the auspices of the Public Health Commission) designated as the fiscal conduit. General oversight of the Project was handled by the Consortium and its Executive Committee.