Community-led structural interventions as a model of empowerment for health and development: The sonagachi / durbar intervention with sex workers in India

ISSUES: Public health interventions face linked challenges mobilizing community participation while navigating community and external priorities and constraints. Those disproportionately vulnerable to disease are often disempowered, lacking the capacities to participate meaningfully or enact changes engendered by interventions. This is particularly salient for women due to persistent gender-based inequities globally. Marginalized communities must ultimately be empowered to be able participate in interventions while addressing other priorities linked to disease risk.

DESCRIPTION: Community-led structural interventions (CLSI) exemplify an empowerment approach. The CLSI model was derived from the Sonagachi Project (Durbar) HIV/STI intervention program with sex workers, a model for the Gates Foundation's scale-up of HIV prevention in India. Durbar evolved from a traditional treatment and prevention services model into an empowerment and community development model with dozens of interventions taking a multi-sectoral response to structural drivers of HIV/AIDS.

LESSONS LEARNED: We synthesized a generalizable CLSI model for incrementally replicating empowerment processes in three stages reflecting Durbar's evolution: 1) community-led implementation through task sharing across intervention components; 2) nurturing a CBO partner for community-led decision-making and action (beyond scope of the intervention); and 3) supporting community ownership by the CBO. Public health professionals mobilize resources and high status networks, advocate for and with the community, create participation opportunities, complement community strengths and weaknesses, and nurture empowerment.

RECOMMENDATIONS: Empowerment interventions are inherently complex and context dependent, which challenges replication efforts based on specific intervention strategies. Public health interventions can adopt an empowerment approach by replicating CLSI processes of community-led implementation, partnership, and ownership.