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BY: ANDREA FINDLEY, MBA, MPA and SUSAN HUBER, MBA

Globalization — the increased interconnectedness and interdependence of peoples and countries — has had a significant impact on international development over the past few decades. The condition of impoverished people in the developing world has become more visible, which, coupled with greater opportunities to contribute, has fueled more helping hands and financial investment in the global development arena. Over just the last 15 years, official development aid has increased by more than 80 percent, totaling nearly $150 billion in 2015.¹ U.S. private giving in the international sector has grown substantially in the last decade, from $8.4 billion in 2000 to $19.1 billion in 2012.²

Although all of this investment undoubtedly offers the potential for providing increased support to people in need, it also poses an important question: Does the external help contribute to lasting, positive change in the lives of people living in poverty?

With that question in mind, Ascension Global Mission chose Guatemala as a starting point for exploring how it might meaningfully contribute to global health challenges. Potential in-country partners — including the Daughters of Charity, Province of Central America — were well established there. Also, Guatemala is within close proximity to the United States and has high rates of seemingly preventable health challenges, including diarrhea, respiratory diseases and chronic malnutrition (the highest rate in Latin America and the fifth highest in the world).

Ascension Global Mission committed to an initial five-year period of listening, learning and working collaboratively with local partners to explore how best to contribute to community health improvement in Guatemala. Since then, the ministry has grappled with how to ensure that health improvements do not exist solely during the life of a project, but are sustained long after. It is tempting to believe that a significant financial investment, an expert-designed program or a brilliant technological advance will make a quick, dramatic and lasting difference in the lives of poor and vulnerable people, but the reality is much more complex. Development efforts that focus on bringing quick solutions may do more harm than good in the long term and unintentionally create dependency and even apathy.

UNINTENDED BARRIERS TO SUSTAINABLE CHANGE
In San Martin Sacatepéquez, a municipality located in Guatemala's western highlands, more than 53 percent of children under the age of 5 are considered chronically malnourished. Chronic malnutrition is the greatest threat to a child's survival and "stymies cognitive and physiological growth in the first 1,000 days of life — from a mother's pregnancy through her child's second year of life. This irreversible stunting dooms children to repetitive illness, inhibits them intellectually and physically, and ultimately reduces their productivity as adults by roughly a third. For society, this adds up to a dire scenario."³ Since 2012, the Guatemalan government has been leading a country-wide initiative to combat the issue. Multiple government agencies, local and international nongovernment organizations, local parishes and donors have aligned towards this effort.

In addition to making immediate donations of food, development organizations also have encouraged households to plant vegetable gardens by providing seeds, donated water filters, provided chickens and pigs to be raised and provided medical services and nutritional supplements. In exchange, these organizations often require some form of community participation — but when the organization's support concludes, more often than not these activities don't continue.

In many communities the practice of distributing food and providing "solutions" has created a culture of dependency and divisiveness. When Ascension Global Mission's local team first started working in San Martin, it was common to hear community leaders ask, "What are you going to give us? What project are you bringing to us?" As dialogue deepened, local leaders expressed frustration that they often are not consulted or even informed of project plans and have no voice in directing how programs and projects get carried out in their communities. In some areas, this has contributed to regular community forums ceasing to function as places for members to discuss and make collective decisions about local needs and opportunities. In other areas, externally driven projects have undermined local community initiatives and have disempowered and divided local leaders.

At the core of Ascension Global Mission's work has been a simple but essential insight: Above all, ensure that all help provided strengthens rather than undermines genuine community ownership. Change is most sustainable when communities embrace it as their own. There is a significant difference between communities that find and enact solutions to their challenges and ones that wait for aid to come to them.

To be sure, it is challenging to break from the more traditional paradigm of giving. For Ascension Global Mission, it has required a willingness to listen more deeply, acknowledge incorrect assumptions and adjust, resulting in a much longer time horizon than initially anticipated. It also has required humility to embrace the notion that in aiding people living in poverty, there is as much to learn as there is to give.

Ascension Global Mission's experience in Guatemala reflects a commitment to patience, learning and flexibility, to discovering misconceptions and blind spots and to exploring and evolving ways to enable lasting health improvement among persons living in poverty. What is now emerging in Guatemala is exciting: a replicable model that enables self-determination, a leading voice by persons living in impoverished communities to improve their own health for the long term. Even more exciting, the model has the potential to drive systemic change from the ground up — the true expression of reverence and subsidiarity.

A MORE EFFECTIVE STRATEGY
Initial research concluded that although people living in poverty would benefit from improved access to quality medical care, many of the challenges they face need to be addressed outside hospital walls, in their own homes and communities. Ascension Global Mission's leaders reasoned that if they invested time and resources only in supporting the current international mission activities of Ascension's health ministries — primarily short-term medical mission trips and donations of medical supplies and equipment — they might miss an opportunity to contribute to a broader vision with greater long-term impact and opportunities for new learning.

Ascension Global Mission first entered Guatemala to identify national and international partners open to collaborating on a health improvement initiative that would focus on two of the leading causes of suffering in children under 5 years of age — diarrhea and intestinal parasites. There were many related initiatives already underway in Guatemala, each with its own focus and approach. Ascension Global Mission's initial analysis concluded that a significant challenge to achieving permanent improvement of these health issues was primarily a technical one that could be solved if health experts came together to design solutions and fund local organizations to implement integrated interventions, including clean water.

However, as the strategy developed, concerns about long-term sustainability surfaced as the approach depended on ongoing funding and did not sufficiently leverage the know-how and current efforts of organizations already working on the ground. So in 2014, Ascension Global Mission established a dedicated space for dialogue and discovery with key local partner organizations (the National Council — see sidebar page 66) interested in working together to develop an approach to community health work that would provide greater and longer-term benefit to people living in poverty. Ascension Global Mission and National Council partners began to explore how to undertake an integrated health improvement initiative by increasing coordination and collaboration of existing efforts involving more than 25 organizations operating in the municipality of San Martin Sacatepéquez.

Although there was a good deal of local interest for this approach, which was envisioned to help organizations have more collective impact, it soon became clear that this way of working was within the same paradigm of "top down" development — from municipal to community, with the community being the "beneficiaries" of the efforts. Deeper analysis with local communities revealed that there was already an evident culture of paternalism present, of community leaders not being asked, encouraged and supported to take lead responsibility for their community's progress, and, as a result, waiting for the next project to come to them. National Council partners felt it was essential to transform this paradigm, which they believed was a root cause of continued poverty and underdevelopment in local communities.

Reflection and discussion among the National Council members motivated a significant shift in the strategy to a focus on community governance; to support local community leaders in a discovery and decision process about what they believe needed to be addressed, and to enable them to move to action.

With the intention of contributing to community-led health improvement beyond just San Martin Sacatepéquez, Ascension Global Mission and the National Council are focused on developing a replicable approach, a model for collaborative governance in health, that other organizations can also adopt and adapt.

LEARNING ALONG THE WAY
The evolution of this initiative represents a steep learning curve. Following are some of the most important insights and operating principles to date:

The desire to "do no harm" is more difficult than it seems. The predominant paradigm in global health is to do for people as opposed to helping them to do for themselves, potentially creating harmful dependency. In Guatemala, many projects may have the input and "participation" of local communities, but not their ownership. Leading donors and organizations increasingly acknowledge that to ensure sustainability, communities need to be the genuine leaders of any health improvement agenda. However, few organizations invest in developing this capacity. Instead, there is a greater focus on identifying what local people need and bringing it to them, making them the recipients of development, rather than the engines of it.

Ascension Global Mission's initial strategies sought to address the root causes of Guatemala's health woes, but still focused tactically on providing for people instead of supporting their efforts to do for themselves. The strategy evolved as Ascension Global Mission and in-country partners explored in greater detail the barriers to enabling sustainable change.

It is important to find a balance between what's needed and what the ministry can offer. Ascension Global Mission initially identified an area of need in global health — the importance of strengthening health infrastructure such as water, sanitation and hygiene — that did not clearly align to its core health care system competencies. With little experience in the international arena, Ascension Global Mission reasoned that a strategy using Ascension's experience in catalyzing, convening and collaborating with diverse partners to co-create a more comprehensive approach would be a valuable contribution during this initial stage of global health involvement.

In hindsight, Ascension Global Mission missed an important opportunity to simultaneously see how it might creatively build on the core capabilities and competencies of the broader health system.

Investing time and committing to a collaborative learning approach is essential. From the beginning, Ascension Global Mission leaders committed to a learning approach in Guatemala. They spent the first few years in dialogue and exploration with local organizations. An openness and willingness to listen, learn and adjust the approach as necessary was crucial. Ascension Global Mission placed its priority on what it could learn in an extended and deliberate process, rather than on achieving its initial goals according to a strict, predetermined time line. At every step, leaders asked, "Is there a better way to achieve the ultimate objective of sustainable health improvement?"

It took time and patience to build trusted relationships with local partners, but working in collaboration with them enabled a co-created initiative to emerge that will have far-reaching and long-term impact.

There is value in thinking big, yet it is important to directly engage communities more quickly. In Guatemala, Ascension Global Mission saw value in creating a long-term vision that could foster broad impact. Without it, leaders may have been so focused on providing benefit for one person, family or community that they would not have considered how to design for replication or fit with the broader community and health care systems. However, it was important to move quickly from the big vision to an in-depth understanding of the challenges and complexities at the community level, and cultivate the local relationships that would enable the development of a realistic approach.

In hindsight, it would have been helpful to have invested time listening and learning at the community level earlier in the process. The strategy might have evolved more quickly.

Willing local partner organizations are important, but co-leaders are essential. It was not enough to have potential partner organizations interested in working together. Local partner organizations, and individuals within them, need to be committed, capable and interested in leading. Ascension Global Mission initially went to Guatemala to gauge local organizations' interest in collaborating to enable sustainable change, but it did not make it a prerequisite to establish a co-leadership role with a capable local organization. Ascension Global Mission had envisioned serving as the convening leader, but it had no prior experience in-country and no established infrastructure. As a result, the ministry had to develop that capacity on its own, which took time and had its own set of challenges.

In hindsight, it would have made sense to establish from the beginning a co-leadership relationship with a local organization that had the appropriate context, insight and infrastructure to enable operations.

Working in partnership with a well-established, in-country organization has been invaluable for establishing credibility and trusted relationships. Ascension Global Mission is a Catholic ministry. Consistent with its commitment to support the work of men and women religious in developing countries around the world, it was interested in exploring how to co-create an approach to address the root causes of poor health. Guatemala was considered for the initial pilot due, in part, to the strong presence of the Daughters of Charity, Province of Central America. From the very beginning, Ascension Global Mission engaged with the Provincial Council and other sisters working in health-related activities in Guatemala to gain greater insight into the health challenges that persons living in poverty were facing. Throughout the past four-plus years, the Daughters of Charity have played an invaluable role in providing ongoing guidance and support to the development of this initiative. They helped to establish credibility and build trust with all levels of people and institutions — high-ranking government officials, departmental health officials, local development organizations and local community leaders.

Traditional metrics are insufficient when working toward sustainable development. Initially Ascension Global Mission invested time and resources to establish traditional monitoring and evaluation.

For example, leaders wanted to be able to report the number of children with access to clean water, sanitation and health education, and link that improved access to better health outcomes. Although it is important to measure the impact of efforts in terms of what has been achieved (e.g., number of people with access to clean water), it is critical also to focus on how the impact came about. Are community leaders better equipped to identify and manage needs and challenges, or has the process weakened them? It is arguably much easier to measure and takes less time to give someone a fish rather than invest in teaching him or her how to fish — even more so when the goal is to support a community to ensure that fish continue to flourish in their waters, or that the community doesn't lose the right to fish.

Ascension Global Mission's strategy in Guatemala has evolved to a focus that supports local communities' efforts to lead their own development agenda. As a result, the metrics are shifting to focus less on program interventions and more on longer-term outcomes, including local governance (how communities are assuming more leadership of health issues) and collaboration (how they are improving their ability to access outside resources to realize their own plans). Health improvement of persons living in poverty remains the ultimate goal, but the methods of achieving that goal are crucial to sustainability.

This work is a lesson in humility. With so much apparent need and suffering in the developing world, there is a natural desire to help. Well-meaning individuals and organizations can rush to offer services and support without taking the time to understand what local communities ultimately need or want. From the beginning, Ascension Global Mission believed that it approached the work in Guatemala with a good degree of openness, seeking to listen, continuously learn and co-create with others instead of coming to the table with a solution to the issues identified. Yet, initially Ascension Global Mission believed answers to the health challenges that communities were facing had to be found and mobilized outside these communities because they appeared to be so resource-poor and vulnerable.

As the strategy has evolved, Ascension Global Mission has recognized that while its initial approach was openness, it also requires being humble. Ascension Global Mission is focused on deepening its humility and reverence for the people it is seeking to serve, but it acknowledges that there are more opportunities for growth. The collaborative governance model, at its core, is focused on raising local community members' voices so that their perspectives and ideas can serve as the foundation for planning. However, it goes further, beyond just a mechanism to enable input and participation, and towards supporting communities to lead and advocate for their agenda.

A DIFFERENT LENS
In 2012, Ascension Global Mission began to explore how it might extend Ascension's mission of sustaining and improving the health of individuals and communities, particularly those persons who are poor and vulnerable, beyond the United States. Though Ascension Global Mission went to Guatemala focused on serving the people there, the experience has brought home a new and unique lens through which to see Ascension's broader global ministry work. "Out of the system" experiences like this one offer an opportunity to reflect and innovate to face changes in the circumstances.

Pope Francis, in an address to the United Nations on Sept. 25, 2015, said, "To enable men and women to escape from extreme poverty, we must allow them to be dignified agents of their own destiny."

Dignified agents, not dignified recipients. The model for collaborative governance in health that is now being developed is centered in authentically elevating and hearing the voices of local people in order to allow their perspectives and ideas to define transformative decisions and actions. This is not Ascension Global Mission's creation. Rather, it is the outcome co-created with Guatemalan faith-based partners who see the shortcomings of the predominant paradigm of development aid in their country and have united with local communities to work for a systemic change.

This is still learning in process, and there is still a lot to learn. Ascension Global Mission welcomes dialogue and debate to help further perspective on approaches that will help enable sustainable health improvement.

ANDREA FINDLEY is senior director, Ascension Global Mission, St. Louis, and oversees the Guatemala initiative.

SUSAN HUBER is senior vice president, global mission, governance and sponsor relations for Ascension, St. Louis.

NOTES

1. https://data.oecd.org/oda/oda-by-sector.htm#indicator-chart.
2. Global Impact, 2013 Assessment of U.S. Giving to International Causes (Alexandria, Virginia: Global Impact, 2013), 4. www.charity.org/sites/default/files/userfiles/pdfs/Assessment%20of%20US%20Giving%20to%20International%20Causes%20FINAL.pdf.
3. USAID, "Our Neighbors, Ourselves: Guatemala's Chronic Malnutrition Crosses Borders," Frontlines (November-December 2011) online edition. www.usaid.gov/news-information/frontlines/50-years-and-food-security/our-neighbors-ourselves-guatemala's-chronic.