The 2014 Ebola outbreak in West Africa resulted in a considerable number of lessons learned for humanitarian and development organisations and associated community engagement initiatives that responded to the outbreak. The objectives, approaches and quality of these programmes varied immensely, and a lack of clear information about individual programme design and resourcing meant that community engagement efforts were difficult to assess and associate with impact. One primary lesson of the Ebola outbreak was the need for better management and measurement of community engagement initiatives. Without such evidence, it may continue to be difficult to justify resourcing community engagement programmes to be at the scale and quality required to make a difference, especially when other needs are so acute.
In light of this, UNICEF Communication for Development (C4D) has initiated a project led by Jamie Bedson (a development practitioner) and Sharon Abramowitz (an anthropologist) to take a proverbial ‘breath’ and ‘step back’ to appraise the information that is available about community engagement in humanitarian and development practice broadly, including during the West African Ebola outbreak. UNICEF believes that the lessons to be learnt can inform a globally shared resource and platform currently being developed, that will support the implementation of high quality and evidence-based community engagement into the future.
Jamie and Sharon are undertaking an international consultative process - which has included members of Mesh - to develop ‘Minimum Quality Standards and Indicators for Community Engagement’. The hope is that these will support the meaningful integration of community engagement standards and activities into all aspects of community engagement practice; informing project cycle design, methodologies, participatory approaches and the integration, coordination and operations of engagement practices within the wider response and research context.
The focus of the work is to see essential minimum standards implemented that create an enabling environment for communities to be listened to, and in turn to engage in the processes and with the issues that affect them. Their application might also recommend comprehensive actions for contexts that require more intensive community engagement such as during a health emergency.
The project, in part, results from an earlier initiative funded by the Bill & Melinda Gates Foundation. That initiative explored ways to evidence the impact of community engagement programmes in health terms through retrospective mathematical modelling. UNICEF’s minimum standards project is also funded by the Gates Foundation.
In this conversation, community engagement is understood as an approach employed by development initiatives and humanitarian response to ensure that communities - especially those at the greatest risk - are active stakeholders, based on transparent and open information flows, in the deliberations, consultations, decision-making, design, implementation and measurement of initiatives and systems that affect them; taking ownership and action on the issues facing them, and ensuring that communities have mechanisms to provide feedback as to the conduct and effectiveness of services.
In this instance community engagement can be differentiated from risk communication, behaviour change communication or KAP (Knowledge, Attitudes and Practices) studies in that it focuses on issues such as participation, inclusion and ownership rather than changing specific behaviours. Also, we are talking primarily of community engagement that takes place in the immediacy of an outbreak and so there is a focus on approaches which are primarily motivated by concerns to see the effective roll out and impact of a health programme, as well as in seeing improved health related behaviours within communities. Having real world data at scale creates an opportunity that other engagement programmes in other times are unable to benefit from, either because they are not associated with such large scale programmes, or are lacking quantifiable and measurable outcomes such as definite health states (perhaps looking to meet ‘softer’ end goals around relationship building, ethical conduct and empowerment over longer periods of time which makes attribution difficult).
The relevance of these minimum standards to engagement in Global Health research is a conversation that is underway. There are bound to be cross-cutting lessons and potential for practitioners to think about their own programme design and resource in light of these. Jamie kindly spoke with me and shared his story.
Can you talk about the origins of the work that you are doing? I sense that this is born from a frustrating situation?
Community engagement can be misunderstood because it is difficult to compare across sectors and contexts and to measure its impact, and so it suffers in terms of attention and resource. We talk a lot about ‘the what’ of community engagement: ‘We want to talk to communities and engage in conversation’, ‘We will listen to them’ and so on, but there is often a big gap in between this and ‘the how’. Perhaps we know broadly what we want to achieve and we know what the principles are but what are the operational, coordination and integration capacities that are needed for this to take place? That is what we focused on to a large degree.
And how did you personally get involved in this?
I went from working for a development NGO on issues of youth health and civic participation to being in the middle of an epidemic when the Ebola outbreak started.
I was Country Director for an organisation called Restless Development in Sierra Leone from 2012 and was running their youth volunteer programming (it might be compared to ‘Peace Corps’ but for young Sierra Leoneans being placed in rural communities in their own country). The Restless Development team was working with young people in Sierra Leone doing essentially community engagement, although people at Restless Development may not have have called it that before the Ebola outbreak. They were doing sexual and reproductive health programming in schools, creating linkages between community infrastructure such as health systems, the police and schools.
In May 2014, Ebola came. So, we were there at the beginning and we realised that we were one of the few organisations that was in every district and had direct contacts with a large number of communities (Restless Development had placed volunteers in 50% of chiefdoms nationally over the previous decade). A group of partners established something called the ‘Social Mobilisation Action Consortium’ (SMAC) which, consisted of GOAL, Restless Development, BBC Media Action, the CDC and a Sierra Leonean organisation called Focus 1000. Together we developed a community engagement programme using the Restless Development model building on participatory processes to identify issues and develop action plans with communities. This was done in 12,505 communities nationally. In most communities, mobilisers didn’t go door to door, which is the common model in these kind of epidemic situations. Instead they had about 10 communities each and they would visit these in rotation and support communities to develop action plans and collecting data every time they went. So we had this vantage on what was happening in communities at a huge scale and by feeding this information back we were able to monitor and support the response. It is testament to the team that none of the 2500 mobilisers contracted Ebola. What they achieved was incredible.
By March 2015 - a year into the response - the Government of Sierra Leone, UNICEF and UNMEER, with support from SMAC partners, developed standard operating procedures for community engagement. The idea with those was that we had guidance and protocols on how community engagement interacted with every single aspect of the response. So, you have: Community engagement for burials; Community engagement for surveillance; Community engagement for hospitalisation and treatment centres etc. Although these were developed very late in the response, the huge collaborative and consultative effort of developing standards demonstrated what can be done and should be done at the start of the response not as late as a year in.
Can you tell us more about some of the issues that arose and how this has informed your thinking about community engagement during a humanitarian emergency?
At the very start of the outbreak in Sierra Leone there was a strategy of ‘We just need to send different messages’ For example, informing people that Ebola is real and, ‘Don’t do A, B and C and you won’t get it.’ And then, when that didn’t work there was a collective shaking of heads and a growing realization that not only was awareness an issue, but all the issues related to how to protect oneself, the family and community, and to how understand and engage with the response - often it was the response to the response that is the issue. While initial messaging was about Ebola only, we were messaging and directly interacting with communities about issues related to treatment centres, the significance of family members being taken in ambulances or safe and dignified, but culturally inappropriate, burials and ‘What happens when you go to a treatment centre?’ and ‘What should you do in A, B, C etc.’ Community engagement is about listening to what community concerns were then taking them to the decision making centre, making sure that they had policy change within the response.
Also, an essential element of quality community engagement is the engagement/ mobilisation officers. Many of them are community members and volunteers. Also, many of them are very young. There should be a primary focus on their training and support. This can be seen as an outcome of community engagement initiatives since they will inform the work going forward. If they are treated as a means to an end rather than the end in themselves then I think that you are missing something crucial about community engagement. In the case of the Ebola outbreak, it is important to recognise that mobilisers, who weren’t official staff, were putting themselves at risk for their communities. It was mobilisers who would go into communities where there were potential Ebola cases. Focusing on the mobiliser and centring the programme around them brings into play all the structures that need to take place: regular training, communication, security, making sure there is data collection etc. These are the things that often don’t get funded.
Why do you think engagement can be under-resourced?
Often social mobilisation is considered a ‘soft’ intervention in comparison to the ‘hard’ interventions of health, education and nutrition delivery. While there is strong agreement that community engagement is important to development, just what this should look like to be effective varies widely.
While there is evidence that community engagement works, we don’t have strong evidence about what models work and where. Therefore, it is difficult to quantify and advocate for in terms of resource allocations. Funders, understandably, are more willing to fund activities that are linked to a stronger evidence base or are more tangibly visible
That’s why there is an opportunity to develop an agreed set of standards and means of measurement to encourage shared understanding across all partners of what it takes to create an enabling environment for effective community engagement, to encourage quality and accountability and build an evidence base.
So, tell us more about the ‘Minimum Standards’
UNICEF C4D are undertaking a consultation process with partners and their country offices to develop minimum standards and indicators to address some of the gaps identified in terms of quality, accountability and harmonization of community engagement in development and humanitarian practice.
Although the need has been identified, it is a significant undertaking as a large number of partners across different sectors employ community engagement approaches and have done so for a long time. However, the challenge is that as of now there are no agreed international standards, or a shared language or understanding of what community engagement as a process and practice is. This is not just horizontally across governments and implementing partners but vertically.
The standards will encourage a shared set of minimum approaches to community engagement by focusing on not just the common principles of community engagement, but also implementation across the project cycle, coordination and integration across organisations, government and within sectors, operational issues such as resources and budgeting, along with appropriate ways of measuring these,
On a personal level, a key lesson coming out of the Ebola experience was that community engagement is not just about reaching into communities and counting how many times you reached them or how many messages that you gave. The operational and organisational mechanism for doing that are important, along with how well community engagement is coordinated and integrated contextually in any given country.
But people might argue that engagement is a complex social intervention and contextual and that it important to evaluate it using an approach that is sensitive to these things? What would you say to this?
Of course during the development of the standard we have had conversations about the challenges of developing standards for an approach that is so dependent on contextual factors, on the specific nature of communities and the initiatives with which they are engaging. We have had feedback both ways, saying that the standards should be relatively broad and high level so as to not be overly prescriptive, but also that this is an opportunity to actually try and be more prescriptive and drill down on those shared, fundamental elements that must be included as minimum standards.
To address this we are consulting with a wide range of partners, including within working groups established for the consultation process, to ensure we get the balance right. The standards and indicators have to be fit for purpose and a useful tool for the leaders and practitioners from institutions and that design, implement and fund development and humanitarian response that incorporate community engagement approaches.
How important do you think that some of the softer goals such as ‘empowerment’ are which can accompany health related goals such as rolling out of a public health programme or informing behaviours to benefit public health?
Core principles such as empowerment, participation, and ownership are essential elements of the minimum standards framework. The ‘minimum standards’ include operational standards such as budgeting and human resources. They look at coordination between NGOs, between NGOS and government, between NGOS and communities etc. By bringing operations and coordination integration into consideration we are putting some structure or potential structures around things.
How do you imagine the minimum standards being used?
Our hope is that the standards will be valuable to some degree for all aspects of the enabling environment for community engagement, with an emphasis on programme design, budgeting, implementation and evaluation. The hope it that is will be a resource for policy making, enabling comparative understandings of engagement across contexts, assisting funders to evaluate proposals and supporting conversations between funders, governments and implementing organizations. Also, the hope is that they will be used in conjunction with other standards, for example the Sphere standards. Although not targeted towards the research community, we also hope that there is some value to those doing research or wanting to engage communities in clinical trials and it helps in taking the issue of community and public engagement forward for those working in that sector.
And so what are the next steps for this work once you have developed and published the minimum standards?
Currently there are plans to undertake a review with key stakeholders of the completed standards in early 2019, during which there will be discussion on next steps for how the standards are shared, validated and operationalized.
We will also be integrating the responses from the Mesh consultation undertaken at the end of 2018.
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