We and health

DiscussionThis paper contributes to a modest but growing body of literature on the role of community members and formalized volunteer cadres in responding to emergency situations generally, and the Ebola epidemic specifically.

In overstretched, under-resourced health systems, it is vital to understand both what these entities have been able to do, and why/how they have been able to do these things (enabling features/mechanisms) including contextual factors that support or challenge functionality .

uch understanding may enable the quick, appropriate and systematic engagement of health volunteers and health committees during public health emergencies, rather than ad-hoc and incomplete approaches.Our research during the epidemic documented significant community mobilization, some of which was driven by pre-existing health committee members who assumed responsibilities to protect their communities and to support health system responses to Ebola.

Respondents described extensive inputs of physical labor and served a range of social roles.

They communicated Ebola-related messages to their peers, enhanced provider understandings of community fears, and advocated for community needs within the health system.

Enabling mechanisms that supported community action included the dual orientation of health committee members as community-members and health system-affiliates.

This dual role built community support for Ebola prevention and treatment activities and enabled health workers to better understand and respond to community concerns and fears.

This finding demonstrates the necessity of communication during emergencies wherein the roles, responsibilities, and remuneration of committee members is made clearer among not only health committee members but also providers and the community generally.

Three broader contextual factors may have contributed to the high self-reported level of HMC functionality during the Ebola outbreak. First, the pre-existing relationships between the HMCs and health workers, which developed in non-emergency periods, bolstered health committee willingness to work with the health system. HMC members framed their trust in health workers within broader narratives of efforts to improve access to healthcare since the end of the civil war.

Second, external inputs, in this case workshops provided by IRC and others and the arrival of infection prevention and control supplies, focused HMC efforts and gave members clear direction and purpose.

Third, the unique horror of Ebola, and the recognition that outside intervention would not be enough to protect the community, galvanized community action.

Although the role of health committees during the Ebola epidemic has not been systematically examined in the academic literature, Oxfam has reported in the grey literature on their work in Sierra Leone setting up committees during the Ebola outbreak .

The organization worked in four districts (Western Area, Kailahun, Freetown and Koinadugu) alongside District Health Management Teams and District Ebola Response Coordination to set up 821 health committees . Similar to our findings, the Oxfam-initiated committees identified barriers to prevention, case management, and safe burial.

They also developed action plans to overcome these barriers. Oxfam reported that actively involving health committees in the Ebola response was essential to their work and that people wanted to see community health committee activities continue after Ebola.Findings from this study stress that public health systems should plan to ensure that pre-existing community committees and groups have specific roles during emergencies.

Community engagement during emergency preparedness and response has been emphasized in high-income settings, including with indigenous communities in remote areas of Australia and Canada .

Schoch-Spana et al.

report that “structured dialogue, joint problem-solving, and collaborative action among formal authorities, citizens at-large, and local opinion leaders” during a crisis such as influenza has a range of beneficial outcomes including improving officials’ ability to govern, the application of communally-held resources, and the mitigation of community-wide losses.

However, researchers have noted that health department capacity for community engagement requires dedicated time and financial support to build long-term, trusting relationships . In low-income countries such as Sierra Leone, sustained support of health committees is currently provided by NGOs such as Oxfam and IRC.Since the conclusion of the Ebola epidemic, the government of Sierra Leone has highlighted the importance of drawing on communities to promote health in several documents, most prominently in the “Basic Package of Essential Health Services 2015-2020” .

The package highlights a need for more actors who can serve as interlocutors between communities and facilities, particularly in the aftermath of Ebola when facility-community tensions were heightened.

Focusing on Community Health Workers (CHWs) as key partners to fulfill this role, the package states that the government is codifying CHW training, allocating resources for a national scale-up of CHW programming, and it is in the process of formally including CHWs within the Ministry of Health’s workforce.

While these are promising steps, the Package gives comparatively little attention to the role of other community-level actors such as HMCs.

The package recognizes that such groups exist, but the document falls short of outlining how these groups could be more coordinated, formally recognized, and compensated for their efforts whether amid health emergencies or in routine health care promotion .

Health committees have the potential to improve health system quality, coverage, and accountability in non-emergency periods and were a central component of the Bamako Initiative .

However, harnessing this potential, and extending it to emergency preparedness, requires ongoing health system support to ensure that community involvement includes marginalized groups, that health workers have the incentives and resources to work with committees, and that committees have genuine control over some decisions and resources. We summarize the key “lessons learned” that arose from our research to inform health systems strengthening and public health emergency response in Table 3.Table 3 Lessons learned for health systems strengthening and emergency responseFull size table Limitations and opportunities for further researchThis paper presents self-reported roles and experiences of community members, many of whom were part of HMCs.

We lack data to triangulate these reports, and respondents may have emphasized or exaggerated the effectiveness of their activities to provide socially desirable responses.

HMCs in Kenema (but not Bo) were established in the 2000s as part of an IRC-supported reproductive healthcare program. Although there were no outward signs of data collectors’ IRC affiliation, respondents in Kenema may have sensed or assumed that data collectors were affiliated with IRC and may have then been motivated to present themselves in a positive light. However, the HMCs in Bo were not supported by IRC, and self-reported activities of Bo HMC members did not substantively differ from Kenema members. Overall, we feel the responses represent the range of activities undertaken by community members, but not the effectiveness or frequency of these activities.We do not have data on how other community members, health care providers, or burial teams felt about respondents’ stated activities, which is meaningful given the amount of partnering necessary as an interlocutor between the groups (enforcing bylaws, contact tracing, managing screening and checkpoints, mediating conflicts, and going door-to-door to stop families from keeping sick members at home).

Respondents reported that community members’ initial reservations regarding infection prevention measures eventually waned, but this may not align with community perspectives.

Furthermore, while respondents described camaraderie with facility staff, we do not know if this was reciprocated. Future research could explore how communities and providers view health committees and could work to devise effective, responsible oversight mechanisms.Our respondents were mostly members of HMCs, as identified by health facility staff, other community at large, or other members of the HMC.

It is often not possible to tell within the transcripts if an individual is responding as a representative of an HMC, another entity, or as an individual.

While there is often a clear distinction among NGOs between work that is conducted as an HMC member versus work conducted as hired assistants, respondents were less discerning regarding whether their activities were done in an official HMC capacity or in another capacity.

For example, while the IRC paid community health workers to contact burial teams in the event of a death and to conduct screening (and did not consider these tasks as inherent to the HMC experience), respondents who were paid saw the tasks as intertwined with their community health worker role.

We could not assess inclusivity of HMCs (i.e. how members came to join the HMC, which community members were excluded) and how the membership mix of the HMC may have influenced their activity.

While it is possible that the Ebola emergency compelled communities to temporarily disregard internal power inequalities and struggles, it is also possible that respondents chose not to discuss these issues during the FGDs for a range of reasons (such as an inability to speak freely in a group setting, to avoid exacerbating tensions, or to present a positive image of their group in hopes of future NGO engagement), or because they were not explicitly asked about it.

Finally, we want to underscore that this data was collected at or around the height of the Ebola epidemic; the ability to maintain or sustain high levels of motivation as an epidemic wanes or ends merits further research.

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