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The Research and Policy Challenges of Scaling Community-Based Health Care…
The Research and Policy Challenges of Scaling Community-Based Health Care (CBHC)
Defining the Problem
Core Description
While CBHC models are effective in addressing local health inequities, they often fail to scale within dominant systems. This isn’t due to flaws in the models themselves, but because health institutions treat scale as a technical process—favoring control, efficiency, and measurable outcomes—rather than a relational and ethical one grounded in equity and community leadership.
Key Challenges
Technical vs. Relational Framing
Institutions tend to treat scale as a neutral process of technical replication. In contrast, CBHC scale requires relational, context-specific adaptation.
Equity vs. Efficiency
Policy systems prioritize measurable, short-term outcomes over long-term investments in trust, prevention, and relationship-building.
Power and Legitimacy
The failure to scale reflects whose knowledge and leadership are valued. Biomedical and institutional expertise are prioritized over lived experience and community knowledge.
Guiding Questions
What counts as legitimate care in health systems?
Whose voices are included or excluded in decisions about scaling?
Can a relational, equity-driven model be institutionalized without losing its essence?
Systemic Barriers to Scaling CBHC
Fragmented Governance
Health, organizational, and social sectors operate in silos, with little coordination
Lack of aligned policies and leadership between ministries prevents long-term integration
CBHC initiatives remain “peripheral” or stuck at the pilot stage
As Raphael (2016) notes, these aren’t technical flaws—they reflect political choices and priorities
Inflexible Funding Structures
Funding prioritizes clinical, short-term, and measurable outcomes
Preventative, relational care is undervalued because it’s harder to quantify
Programs like CBHiD face uncertainty due to inconsistent or insufficient resources
Kim, Farmer, & Porter (2013) argue that funding must redefine “value” to include equity, access, and community trust
Professional Hierarchies
Clinical and academic authority dominates health decision-making
Peer educators and community workers are often tokenized—not empowered
Lived experience is undervalued compared to credentialed expertise
Brookfield (2012) urges critical thinkers to challenge institutional norms; Reich (2021) links this to power and positionality
Stakeholder & Competing Perspectives
Peer Educators & Community Workers
Bring lived experience, cultural knowledge, and relational trust
Central to CBHC effectiveness in marginalized settings
Often included symbolically and may excluded from strategic leadership
Their insights are frequently undervalued by formal institutions
Institutional Leaders & Funders
Driven by risk management, accountability, and cost-efficiency
Prefer standardized models and replicable interventions
Often hold the most structural power over whether CBHC is scaled or sidelined
Researchers & Practitioners
Split between
Those who follow evidence-based, replication-focused paradigms
Those committed to equity, reflexivity, and co-creation
Positionality plays a major role in shaping their values and approach
In my own research, I observed this divide firsthand—especially around how success is defined (e.g., outcomes vs. relationships)
My Perspective
Grounded in a constructivist, equity-driven worldview
Advocate for co-creation over replication, and for the inclusion of non-dominant knowledge
View scale as a relational, iterative process—not a top-down rollout
Committed to ethical reflexivity, humility, and systems thinking
Researcher Reflexivity
Personal Reflection
I initially believed strong program design would ensure success.
In reality, success depended more on local trust and shared leadership than on structural fidelity.
In resistant contexts, even a well-evidenced model faltered due to lack of power-sharing or tokenization of peers.
Key Reflexive Questions I Faced
Am I amplifying community voices—or unintentionally reproducing dominant norms?
How do my academic goals shape what I highlight or exclude?
Whose interests do I serve when I present “findings”?
Cognitive Skills in Action
Analysis
Broke down complex systemic problems like fragmented governance and tokenized participation
Mapped how structural forces (e.g., policy silos, funding models) affect local implementation
Distinguished between symptoms (e.g., stalled programs) and root causes (e.g., lack of shared power)
Example:
Noticing that program delays weren’t just bureaucratic—they reflected political resistance to peer leadership.
Evaluation
Judged how well CBHC interventions aligned with values like equity, inclusion, and sustainability
Weighed competing logics (e.g., institutional efficiency vs. relational trust)
Assessed not just program results—but the ethics of how those results were achieved
Example:
Questioned whether scaling a program quickly without adaptation compromises its core relational values.
Reflexivity
Regularly examined my positionality as a student, outsider, and knowledge contributor
Asked: How do my institutional affiliations influence what I see or report?
Practiced ethical self-regulation by adjusting my engagement with community and institutional stakeholders
Framework link:
Aligned with Reich (2021) and Brookfield (2012) on reflexivity as a core research practice.
Systems Thinking
Identified interdependent barriers (e.g., how funding policies reinforce hierarchies)
Recognized feedback loops and unintended consequences of top-down scale
Saw CBHC not as an isolated model, but part of a broader, inequitable system
Framework link:
Connected to Trochim et al. (2006)’s emphasis on systems thinking in public health practice.
Dialogue & Synthesis
Engaged with peers, supervisors, and community stakeholders to explore multiple perspectives
Balanced methodological rigor with ethical and relational sensitivity
Synthesized academic, policy, and lived experience knowledge to inform my position
Example:
My view evolved through conversation with those who emphasized outcome data vs. those who prioritized community process.
Programs, Tools & Models
Global Frameworks
WHO Primary Health Care (PHC) Framework
Promotes integrated, people-centered care
Encourages cross-sectoral collaboration and accountability
Frames health as a social and political determinant, not just a clinical outcome
Emphasizes equity, empowerment, and sustainability
Canadian Tools & Models
National Collaborating Centre for Determinants of Health (NCCDH)
Offers training and tools to embed equity into public health planning
Supports reflexive, systems-based change at the organizational level
Useful for shifting institutional mindsets toward justice-focused outcomes
Indigenous-Led Health Hubs
Model co-created, culturally grounded care
Prioritize community leadership and local knowledge
Proven to increase trust, engagement, and long-term health outcomes
Practice-Based Example
CBHiD Program (My Case Study)
Real-world example of a CBHC model implemented across multiple systems
Offers insight into how local politics, governance, and hierarchy shape scale
Reinforces the need for relational infrastructure and political will
Peer-Led Harm Reduction Networks
Grounded in trust, lived experience, and non-judgmental care
Models for de-medicalized, community-led health interventions
Resilient, adaptive, and cost-effective—yet often politically unsupported
Philosophical & Ethical Foundation
Constructivist & Interpretivist Worldview
Health, knowledge, and care are socially constructed
Local context, relationships, and values matter
Universal solutions are often inadequate or harmful
Encourages flexible, community-responsive scale—not rigid replication
Ethic of Care (Reich, 2021)
Research and policy must be grounded in empathy, trust, and accountability
Care is not just what we deliver—but how we relate to each other
Calls for humility in the face of complexity and difference
Highlights the responsibility of the researcher to act relationally and ethically
Application:
In CBHiD, I practiced care ethics by reflecting on my influence and prioritizing community voice.
Equity as Power Redistribution
Inclusion is not enough without structural change
True scale must disrupt hierarchies and center marginalized voices
Peer-led models are not “add-ons”—they are a redefinition of expertise
Systems must evolve to support—not suppress—community leadership
Co-Creation Over Replication
Scaling is not a matter of copy-pasting successful models
It requires dialogue, negotiation, and adaptation
Programs must evolve through ongoing relationships with communities
As Lorusso et al. (2021) note, design thinking can support participatory problem definition
Scale is a dynamic process—not an endpoint.