Fostering community-led solutions and ensuring community ownership of the response
Current context: April 2019
As of April 5th, 2019, there were a total of 1,117 Ebola cases (1,051 confirmed, 96 probably) 702 death, and 339 people cured. Following the epi-data from Katwa/Butembo and Mangina over the past month, there was an increase in community deaths, which clearly indicated a decrease in trust towards the response (according to the Ministry of Health’s Sitrep on April 3rd – between March 13th and April 3rd 50% of the 44 cases in Katwa were community deaths). With the resurgence of cases, there was a diminishing amount of trust from communities. As well, the Response, as a whole, had for the most part not managed to close the feedback loop.
Building relations of trust can only be done with a constant presence in communities, through the highs and the lows of the outbreak, and building relations, past the initial stage of involving local leaders and people in positions of power. It means being present, in a constant and available way, to help communities structure their involvement in the response, for an appropriation of the response structure, and most importantly to enable the response to have more community-based and community-led solutions to understand how to increase community trust in the response, and support local health structure in IPC/ WASH to ensure that when communities do choose to trust these structures there are means to support and when necessary refer them to the proper treatment centers.
Given the context, it was important to have a stable presence in zones of intervention regarding the Ebola outbreak. There was a need to be complementarity between “rapid-response teams” and grassroots prevention work done through a community engagement way of working. Rapid Response Teams give flexibility to the response, which had been severely lacking. However, this type of intervention does not give time and place to build relations of trust, which is a critical component to ending an outbreak.
Oxfam in the Response
Oxfam’s overall objective has not shifted: we believe that we need to enable communities to take ownership of the measures put in place by the response by providing adequate information on the epidemic and creating space for participation as well as increased confidence in health services by providing, if necessary, support in the form of WASH services in health facilities1.
Oxfam’s aim is to support the community’s involvement and ownership of the Ebola Response through a community engagement way of working. This is a planned and dynamic process of involving communities affected by the crisis in the response so that the delivery of services, infrastructure, and processes works for them.
As such, by working with and through a community network, where respect for local culture and beliefs will be ensured, Oxfam aims to foster a safe and supportive space to enable communities to develop tailored public health promotional activities to promote behavior change in prevention practices to EVD: increase health-seeking behavior of the community and acceptance of critical Ebola response mechanisms (surveillance, case management, vaccination, etc.), with the aim of strengthening a bottom-up approach and equipping high-risk population groups with the ability to prevent/reduce the risk of transmission.
Oxfam’s work with community structures (CAC)
Oxfam’s community-centred approach has led us to identify, through social mapping, local influencers from community-based associations and networks such women groups, youth initiatives, marginalized groups and religious structures and facilitate the set-up, or reactivate existing, cellule level committees (the politico-administrative unite that is smaller than a neighbourhood), composed of 8 to 10 people. The goal is to have representation from diverse groups in the community, including those in the highest position of vulnerability.
These cellule level committees’ (CAC) meet on a regular basis, based on their community needs, the epidemiological situation and security assessments. The CAC are trained on key actions to prevent and reduce the risk of Ebola as well as on the principles of dialogue and protection. To build confidence in, and acceptance of the response, Oxfam provides support through continuous training, access to accurate and relevant information, in close coordination with other response actors. This could be around the importance of the different Ebola interventions for prevention and risk reduction such as safe and dignified burials, vaccination targeting and objective, contact tracing and referral. Feedback from those community structures is being used to identify priority barriers and joint action plans will be developed promoting locally appropriate solutions.
CACs, with the support of Oxfam teams, when necessary, identify the key barriers to eradicating the Ebola epidemic based on epidemiological trends and community feedback in their locality and map out community action plans to outline practical solutions to address the identified barriers.
The central element of this approach is the Community Action Plan (PAC). Through the PAC, the community prioritizes and manages community measures to achieve its objectives and leads their deployment and implementation, setting distribution criteria, execution modalities, etc. Co-management through PAC allows communities to have an overall vision, as well as to preserve an integrated space for discussion and decision-making that guarantees that the right of the community to participate in decision-making is fully effective.
To contribute to PACs inclusiveness Oxfam developed the Community Perception Tracker or the CPT. The CPT is a co-management tool shared with communities that allows community members to be at the center of decision-making in all program activities underway within the community. The CPT allows systematic collection and analysis of rumors, beliefs, or ideas circulating among people affected by an emergency or humanitarian crisis. The CPT has been designed to complement the PACs so that the insights gathered in communities allow, through shared analysis with communities, immediate programmatic change.
To ensure that PAC management is broadly representative and that all groups in the community are listened to, Oxfam’s community approach also provides other tools that should accompany the community engagement process:
- Consultations with excluded or vulnerable groups allow us to reach those groups of the population that we have identified through community mapping or protection analysis and that are not participating in the co-management of the PAC. The consultations are a tool to improve the design of the program and adapt it to the needs of the most vulnerable groups.
- Monitoring the level of satisfaction and participation of the community through spider web exercises allows us to monitor the level of acceptance of the program within the community and introduce the necessary programmatic changes in the community engagement process to ensure that we are listening to all groups in the community.
- Community round tables allow communities to assess protection risks making it possible to guarantee safe programming from a community perspective, monitoring the situation and the level of acceptance through dialogue with local authorities, religious leaders, and other significant actors at the community level.
Community measures included in PAC’s aim to demystify Ebola response services, promote preventive behaviors like handwashing with soap, enhance early detection, treatment-seeking behavior, contact tracing, community-based care, and the importance of Ebola health care access through ETCs. When necessary, Oxfam is playing the role of a broker for CAC, and linking solutions identified with other response actors to address comprehension and capacity gaps, increasing accountability towards communities. For example: organizing demonstrations on Safe and Dignified Burials, with the respective actor, briefings by the vaccination teams or organized visits to ETCs.
The feedback from communities and major barriers identified as well as enablers are being shared with the local coordination and respective commissions to foster accountability mechanisms and close the feedback loop.
Where appropriate, and if needed, a local alert system have been set up, in coordination with the surveillance commission, to actively contribute to timely case notification and referral to Ebola Treatment Centers (ETCs).
Risk, conflict, gender, and protection analysis are integrated throughout the program and done with the support of the community. To ignore these differentiating needs and levels of control and access when responding to this emergency will further perpetuate pre-existing inequalities, increase the marginalization of women and girls as well as preserve the image of women as helpless victims. The deployment of specific Community Action Plans under the lead of women’s forums in each community to discuss gender-based inequalities generated by the pandemic was revealed as a particularly useful tool.
Protection mainstreaming is a cornerstone of Oxfam’s Ebola response program: all teams and community associations are trained on protection, how to conduct risk analysis, and the importance of confidentiality and consent.
The provision of WASH facilities at the health center level is critical to reducing Ebola-related transmission risks. The selection of the health centers is done in close coordination, with the IPC/WASH Sous-Commission, with the team of the Bureau Central de la Santé, factoring in epidemiological data, needs of repair, and/or lack of WASH facilities. Oxfam will build on its longstanding experience to develop and adapt designs to ensure that they are locally appropriate.
For more information
This case study was written by:
Lily-Madeleine Seguin – Public Health Promotion Advisor GHT (lily.seguin@oxfam.org)
with support from Manel Rebordosa – Public Health Promotion HSP