Global Health Security Agenda Implementation: A Case for Community Engagement

Abstract

In today's interconnected world, infectious diseases can spread rapidly within and between countries. The 2014-2016 Ebola epidemic in Guinea, Liberia, and Sierra Leone underscored the inability of countries with limited capacities and weak public health systems to respond effectively to outbreaks. To mitigate future health threats, nations and international organizations launched the Global Health Security Agenda (GHSA) to accelerate compliance with the WHO's International Health Regulations, so as to enhance global protection from infectious disease threats. To advance GHSA's mandate to build capacity to prevent, detect, and respond to infectious diseases, and thereby contain threats at their source, community engagement is needed. This article advocates for community engagement in GHSA implementation, using examples from 3 GHSA action packages. A country's ability to prevent a local disease outbreak from becoming an epidemic often rests with the level of knowledge about the situation and the actions taken at the community level.

To advance the Global Health Security Agenda's mandate to build capacity to prevent, detect, and respond to infectious diseases, and thereby contain threats at their source, community engagement is needed. This article advocates for community engagement in GHSA implementation, using examples from 3 GHSA action packages. A country's ability to prevent a local disease outbreak from becoming an epidemic often rests with the level of knowledge about the situation and the actions taken at the community level.

In a globalized world characterized by improved technology and rapid modern transportation, infectious diseases can rapidly spread between and within countries in a matter of hours.¹ The 2014-2016 Ebola epidemic in the 3 West African countries of Guinea, Liberia, and Sierra Leone illustrates how global health security relies on the capacity of all countries to rapidly detect, respond to, and control public health threats. In 2014, more than 40 nations, international organizations, and nongovernment stakeholders launched the Global Health Security Agenda (GHSA) to accelerate progress toward implementation of the World Health Organization's (WHO) International Health Regulations (IHR) and to create a world capable of containing infectious disease threats.^2,3 While the GHSA provides a platform for preventing, detecting, and responding to global infectious disease threats, its process does not include engaging the community. With a focus on 3 action packages—surveillance, emergency response operations, and human resources—we describe opportunities for strengthening GHSA implementation through community engagement. We draw from public health successes that demonstrate how community engagement was pivotal and, in the process, make a case for community engagement in GHSA implementation (Table 1).

Table 1.

Examples of Public Health Interventions with Community Engagement Components Relevant for GHSA Implementation

Project/Context Description	Problem	Role of Community Engagement	Lessons for GHSA
Community-Based Surveillance: A Pilot Study from Rural Cambodia—2005⁴ A pilot study to assess the performance of a community-based surveillance system (CBSS) in 7 rural communities in Cambodia. CBSS provided timely and representative information on major health problems and life events.	• Routine health facilities–based disease surveillance systems were not capturing health problems in communities, as patients without access to public health facilities or who chose not to use them were not reported by these systems.	• Community members were recruited and trained as village health volunteers.^a • Village health volunteers reported suspected outbreaks, important infectious diseases, and other public health–related events occurring in their communities to local health staff.	• CBSS successfully filled in gaps associated with health facility–based disease surveillance. • Village health volunteers were able to conduct regular monitoring of communicable disease trends and provide regular reporting of pregnancies, births, and deaths in rural areas. • CBSS was replicated in 2 districts in Cambodia in 2004 and 2005.
Implementation and Utilization of Community-Based Mortality Surveillance: A Case Study from Chad—2002⁵ Five Médicins Sans Frontières (MSF) sites (2 refugee camps and 3 camps for internally displaced persons) in eastern Chad implemented and used community-based mortality surveillance.	• Difficulty conducting prospective monitoring of mortality in complex emergency settings	• Community health workers were recruited from camp populations and trained to record births and deaths. • Graveyard watchers interviewed families visiting burial sites, collected data, and reported on deaths.	• Mortality data collected by community health workers were used for monitoring population health status and for post-emergency advocacy. • Use of community health workers made prospective mortality monitoring possible in a complex emergency setting.
Promising Practices for Community-Based Surveillance—2009⁶ An assessment of community-based models of avian and human influenza surveillance used in Vietnam, Cambodia, Nicaragua, and Lao People's Democratic Republic to bridge surveillance gaps	• Lack of public health infrastructure for detecting emerging infectious diseases and gaining a better understanding of respiratory infections	• Event-based surveillance in Nicaragua: Clear reporting mechanisms were established to define triggers for surveillance reporting and to ensure understanding and awareness of those triggers by healthcare workers and other allied health professionals.	• Building on past experience and successes in community mobilization, CARE has since 2006 created context-specific community-based surveillance models to increase early detection of avian flu (H5N1) and other emerging infectious diseases.
Key Experiences of Community Engagement and Social Mobilization in the Ebola Response—2015⁷ A commentary on key experiences of community engagement and social mobilization efforts in the recent Ebola response	• Lack of community participation in Ebola response	• Community and religious leaders trained as social mobilizers. Communities were engaged in self-management of quarantines, control of cross-border movement, safe and dignified burials, and the siting and implementation of community care centers.	• The 2014-2016 Ebola outbreak showed that engaging affected communities in response activities helped to reduce high-risk traditional practices that promote Ebola transmission.
Communication for Behavioral Impact (COMBI)—2009⁸ A toolkit for planning and integrating behavioral and communication interventions into public health programs with case studies	• Difficulty convincing community members to take necessary precautions to control Ebola	• COMBI was used to control Ebola hemorrhagic fever in Yambio, southern Sudan. • Social mobilizers and Ebola survivors engaged with community members on behaviors that control the spread of Ebola.	• COMBI is useful for planning, adapting, and strengthening communication interventions for community Ebola and infectious disease outbreak response.
Global Experience of Community Health Workers for Delivery of Health Related Millennium Development Goals—2010⁹ Case studies of community health worker programs and typologies in 8 developing countries address unanswered questions on the role of community health workers in health workforce planning and management.	• Shortage of health workforce to provide essential, life-saving interventions	• Community health workers were recruited to provide a wide range of services to the community.	• Services provided by community health workers helped to reduce the burden and costs of TB and malaria.

Community health workers are known by various names around the world, including village health volunteers, community health agents, community health volunteers, village health workers, and lay health visitors.

Launching of the GHSA

The emergence of infectious diseases such as HIV/AIDS in 1981 and severe acute respiratory syndrome (SARS) in 2002, and the reemergence of avian influenza (H5N1) in 2003, demonstrated the vulnerability of the world to infectious disease threats. Recognizing the effect of international travel and trade on the emergence and reemergence of infectious disease threats, the WHO revised the 1969 IHR in 2005, with the goal “to prevent, protect against, control, and provide a public health response to the international spread of disease.”¹⁰

To facilitate early detection, better coordination, and timely response to infectious disease threats, and to accelerate progress toward implementation of the WHO IHR, the GHSA was launched in 2014. GHSA is a multilateral and multisectoral initiative that seeks to build and enhance global capacity to prevent, detect, and rapidly respond to infectious disease threats by investing in infrastructure, equipment, and skilled health workforce personnel.¹¹ By participating in GHSA, countries can commit to provide funding or technical support to 1 or more action packages and to work together to achieve GHSA 5-year targets.

GHSA Action Packages

In order to implement the GHSA, supporting countries and organizations identified 11 action packages around specific technical areas at the 2014 Helsinki meeting on GHSA Commitment Development, and they reiterated their commitment at the subsequent Jakarta Global Infectious Diseases Meeting later in 2014.² The action packages provide a foundation for public health capacity building and include core cross-cutting system pillars such as strengthening real-time surveillance and information systems, creating a trained public health workforce, and establishing emergency management and operations centers.¹² Each action package includes a 5-year target and is aligned to an indicator or set of indicators by which to assess progress from the WHO's Joint External Evaluation tool (JEE).¹³

The GHSA action packages align with key components in the IHR and the WHO's JEE tool.¹⁴ The JEE tool is composed of 49 indicators that relate to 19 technical areas and corresponding contextual and technical questions. Data collected with this tool provide baseline information about a country's GHSA capacity and its IHR capabilities.¹⁵ Priority recommendations arising from the JEE are used to inform and shape a country's 5-year road map and other national planning efforts. Through the implementation of national and subnational plans across key action packages, countries have an opportunity to comprehensively promote community engagement in a manner that will contribute to increased JEE capacity levels.

The Case for Community Engagement

The term community engagement is often used interchangeably with other terms such as community involvement and community participation to describe a range of activities. For the purposes of this article, community engagement will refer to:

The process of working collaboratively with and through groups of people affiliated by geographic proximity, special interest, or similar situations to address issues affecting the well-being of those people. A powerful vehicle for bringing about … behavioral changes will improve the health of the community and its members. It often involves partnerships and coalitions that help mobilize resources and influence systems, change relationships among partners, and serve as catalysts for changing policies, programs, and practices.¹⁶

Community engagement describes the participation of local people in projects, interventions, or activities that address issues that affect their well-being. It varies in scope from simple information sharing to active engagement.^17-19 When executed programmatically, community engagement may help build partnerships and trust,²⁰ allow for the sharing of responsibilities and decision making, promote listening to and respect for community leaders and gatekeepers, extend projects to hard-to-reach populations, facilitate environmental and behavioral change, and create a group of stakeholders who are motivated to support public health efforts at the community level.

Adopting a community engagement approach to the implementation of GHSA action packages will enhance progress and the execution of strategies, as community partnerships will establish formal and informal networks necessary for health improvement, remove known and unintended barriers, leverage resources, and mobilize community assets around GHSA goals.

The Role of Community Engagement

Over the past few decades, community engagement has emerged as an increasingly effective strategy for harnessing community potential because of the growing recognition of the benefits associated with the approach. Kouadio and colleagues noted that the engagement of local leaders, youth, and women's associations in Liberia during the Ebola outbreak facilitated the reduction of denial, fear, and panic associated with the disease, and encouraged the reporting of suspect cases to the community chief and the district health officer.²¹ In the spirit of community engagement, local leaders in the village of Barkedu in Lofa County raised funds to supplement referral efforts of suspected Ebola cases. They also established watch groups throughout the county to restrict the mobility of infected individuals and to prevent suspicious people from entering the county. Some churches in the county took steps to sensitize their congregations and to discourage people from hiding Ebola-infected individuals at prayer centers.²¹ Recognizing the contribution of community engagement in curbing the 2014-2016 Ebola epidemic, WHO, in addition to establishing outbreak surveillance systems and infection control measures in the affected countries, called for community engagement in all components of the Ebola response.²² According to Ravi and Gauldin, the engagement of community leaders in Ebola response activities increased response effectiveness, as it created trust between local people and outside aid groups and helped with control efforts. This ultimately reduced barriers to healthcare access.²³

Widely used in the 2014-2016 Ebola response in West Africa, community engagement approaches can also be used in other public health intervention efforts, including those associated with GHSA implementation, and especially in surveillance, emergency response operations, and human resources action packages. Examples of successful applications of community engagement to public health interventions with relevance for GHSA implementation globally are presented in Table 1.

For GHSA to be successfully implemented at the community level, the involvement of stakeholders at the district level is necessary. District health management teams (DHMTs), with their mandate and familiarity with the community, will have to be involved. As part of their collaboration with GHSA program managers, these teams can provide guidance on recruiting community volunteers or community health workers and support their community engagement efforts.²⁴

Surveillance

Surveillance is the continuous, systematic collection, analysis, and interpretation of health-related data needed by public health professionals for planning, implementing, and evaluating public health practice.²⁵ Community-based surveillance is a type of surveillance that involves the systematic and continuous collection of data on events and diseases by community members; it uses simplified case definitions and forms to report public health events and diseases to health facilities for verification, investigation, collation, analysis, and response as necessary.²⁶ Community-based surveillance facilitates active community participation in public health surveillance efforts and contributes to early disease detection, rapid disease reporting and response, and the monitoring of health events in communities. It also improves sensitivity to formal surveillance systems and can help to improve community-based disease prevention and mitigation efforts.

Engaging the community in surveillance activities in rural Cambodia led to an increase in the proportion of infectious disease cases that were reported, compared to those reported by passive surveillance systems.⁴ Community surveillance helped with the monitoring of disease trends. Lay people trained as village health volunteers (VHVs) assisted with the detection of common infectious disease outbreaks. Village health volunteers reported cases of communicable diseases, ranging from 65% for malaria to 93% for measles.⁴ The positive predictive value (PPV) of the reports of village health volunteers on communicable diseases ranged from 82% for severe diarrhea to 90% for measles.²¹ In the Central African Republic, community health workers engaged in weekly rural demographic surveillance reporting on births and deaths, resulting in the detection of over 90% of deaths at sentinel surveillance sites and the acceptance of the formal surveillance system.²⁷

The incorporation of community engagement into GHSA surveillance activities, as was done in Cambodia, Nicaragua, and Chad (Table 1), will enhance the early detection of emerging and reemerging infectious diseases, facilitate the collection of mortality data for monitoring population health status, and, in the process, help to reduce high-risk traditional practices associated with disease transmission.

Emergency Response Operations

Emergency response operations involves the preparation for, response to, and recovery from a disaster or emergency. Traditionally, communities have played and continue to play a limited role in emergency response operations. The use of the communication for behavioral impact (COMBI) tool in emergency response demonstrates the utility of community engagement in emergency response efforts.⁸ The involvement of a community volunteer drama group in the 2008 cholera outbreak response in Chinhoyi, a village in Zimbabwe, helped to convey cholera prevention messages to community members, including the need to thoroughly wash hands before eating. Working in partnership with the municipality of Chinhoyi, the community volunteer drama group also participated in contact tracing activities, which helped with the identification of individuals who had been exposed to infected people. Prior to the health education effort, many people in Chinhoyi were unaware of the cause of the cholera outbreak. The activities of the local volunteer drama group created awareness and mobilized community action to respond to the outbreak. As a framework and method for the integration of behavioral and social communication interventions into public health programs, COMBI,²⁸ when applied in the context of GHSA, will promote community engagement in the planning and implementation of emergency response measures. It will also help to address the cultural, behavioral, and social factors associated with disease outbreak prevention and control.

Human Resources

Globalization and the threat of infectious diseases have made it essential for countries to have a strong health system and a sustained health workforce.²⁹ Unfortunately, many countries are experiencing a human health resource crisis—a shortage of qualified health workers, including those who understand animal health—and difficulties recruiting and retaining health workers in areas where they are most needed.³⁰ This reality has implications for the GHSA human resources action package, which emphasizes the training and use of local health professionals such as doctors, nurses, epidemiologists, and veterinarians to implement GHSA activities.

To close the health workforce gap, many resource-poor countries are investing in community health workers and integrating them into their public health workforce. These workers are trained to provide basic health services without receiving any formal professional or paraprofessional certificate or degreed tertiary education.³¹ WHO endorses the use of community health workers and sees them as a potential solution to the human resource crisis affecting many countries.^9,32 Using community health workers to implement GHSA will provide the necessary workforce needed to reach communities and will create stronger communication and information sharing among community, national, and subnational units responsible for surveillance, emergency response, and other GHSA-related activities.

Community health workers have the ability to detect and report suspected cases of disease.²⁹ To sustain their contributions, it is important that national policies and guidelines be established to formalize their terms of reference and to standardize tools for their training. The linkages between health centers and community health workers need to be formalized and their work plans coordinated. Simple community case definitions need to be used to allow community health workers to recognize and report early disease symptoms. This will enhance their disease surveillance efforts.

The continued engagement of community health workers depends mostly on how they can be retained and motivated. While financial compensation is the preferred motivation, it is prohibitive and unsustainable. In Cote d'Ivoire, where community health workers number in the tens of thousands, any attempt to provide monetary compensation, using the minimum wage rate would amount to about $72 million per year (personal communication, director general, Division of Community Health). As a result, symbolic rewards—such as recognition during high-profile public events, opportunities for training, and workshop attendance where they may receive an honorarium—could keep community health workers motivated. This approach has worked in Cote d'Ivoire.

Community Engagement Framework

In the past, community engagement strategies were underused in the implementation of public health efforts, thus hindering the development of local health system capacity.³³ Engaging the community in GHSA implementation may increase community participation in surveillance, emergency response operations, and human resources activities and strengthen countries' efforts to prevent, detect, and respond to emerging infectious diseases. Engaging communities will create relationships that will facilitate the collection and dissemination of information, as community members are closer to the ground and can be activated very quickly in an emergency. This is particularly important in resource-constrained settings, where the strategy can also contribute to sustainability of GHSA programs. Community members learn to work together and to fend for themselves through their engagement; as a result, community engagement can lead to quicker response to health threats as there is less reliance on external help. Using grassroots efforts will be valuable to GHSA implementation. The 2014-2016 Ebola outbreak showed that engaging affected communities in response activities helped to reduce high-risk traditional practices that promoted Ebola transmission.

Community Engagement Challenges

Irrespective of its benefits to GHSA implementation, community engagement can cause community members to become disillusioned if the community engagement process does not lead to action that reflects their input. If not handled properly, community engagement activities can cause less powerful voices and groups to be marginalized in decision making and in the formation of partnerships. In the bid to get the community engaged in GHSA implementation, there is the danger of asking too much of community members, thereby causing them stress and exhaustion.³⁴ For community engagement and partnerships to become standard practice and sustainable, they need to be embedded in ongoing governance arrangements. Without such arrangements, community engagement is likely to be too dependent on the personal relationships between particular professionals and community members, which could be easily lost when people involved leave or move away.

Conclusion

Integrating community engagement into public health activities, including GHSA action package implementation, can enhance countries' abilities to effectively prevent, detect, and respond to future infectious disease threats. Specifically, community engagement can help to build social networks, increase trust, and foster community ownership of public health programs, including GHSA projects. Greater community participation and ownership may increase the likelihood that communities benefit from capacity-building efforts, including those aligned with GHSA.

Beyond GHSA, the application of a community engagement approach to public health efforts globally can yield great benefits. Among other things, it can promote overall community health and well-being and address the causes of disease and disability.³⁵ It can also increase community understanding and appreciation of public health issues, facilitate genuine involvement of communities that have traditionally been absent from the planning of public health processes, and help to create a broad constituency that can advocate for local community health concerns.³⁶

Generally, engaging communities in public health efforts enables them to build their capacity to address public health concerns through the active participation of community members. It also causes community members to use their strengths to create change from within.

Increased international attention and urgency to enhancing global health security has generated resources for accelerated efforts toward improving countries' capacity to prevent, detect, and respond to infectious diseases. This international support offers countries the opportunity to leverage community networks, capacities, and resources that strengthen and integrate disease surveillance systems, human resources, and emergency response operations with those at the national level. Ultimately, the capacity to contain a disease or other public health threat at its source may rely heavily on community-level leaders, workers, and volunteers who have the knowledge to recognize and communicate suspicious events to public health surveillance officers and other officials who can confirm and contain an outbreak.

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