Strengthening community protection and resilience: regional strategy for community engagement, 2023–2030 in the WHO African Region: report of the Secretariat

AFR/RC73/9 28 July 2023 REGIONAL COMMITTEE FOR AFRICA Seventy-third session Gaborone, Republic of Botswana, 28 August–1 September 2023 ORIGINAL: ENGLISH Provisional agenda item 13 STRENGTHENING COMMUNITY PROTECTION AND RESILIENCE: REGIONAL STRATEGY FOR COMMUNITY ENGAGEMENT, 2023–2030 IN THE WHO AFRICAN REGION Report of the Secretariat EXECUTIVE SUMMARY 1. The African Region faces a disproportionately high disease burden. The prevalence of non- communicable diseases, recurring health emergencies, natural disasters, and humanitarian crises put pressure on fragile health systems. Health inequities affect vulnerable populations due to various determinants. These require action from the whole of society and sectors beyond health. 2. Healthcare systems are highly complex social systems shaped by multiple factors, including professional training, institutional values, leadership competencies and priorities, and the wider socio-cultural and economic context. Consequently, communities should be considered integral components of health systems in ongoing efforts aimed at developing more responsive, equitable, and effective health policies for Universal Health Coverage (UHC) and health security. 3. The Astana Declaration on Primary Health Care, the UHC framework for action, and Regional Strategy for Health Security and Emergencies 2022-2030 (AFR/RC72/8) highlight systematic community engagement as a core component for successful implementation. 4. The proposed strategy will support Member States in engaging communities for healthier and more resilient populations by fostering relationships of trust between stakeholders to promote health, minimize risk, and mitigate the consequences of public health events. It provides guidance on leveraging existing community structures and institutionalizing community engagement at the interface between health, development, and humanitarian action. It prioritizes enhanced research, monitoring, and evaluation of community engagement approaches and integration of lessons learned to strengthen health systems and mitigate future emergencies. 5. The Regional Committee is invited to examine and adopt this strategy. CONTENTS Paragraphs INTRODUCTION ....................................................................................................................... 1–5 SITUATION ANALYSIS AND JUSTIFICATION .................................................................. 6–15 THE REGIONAL STRATEGY .............................................................................................. 16–44 CONCLUSION ........................................................................................................................ 45–47 AFR/RC73/9 Page 1 INTRODUCTION 1. The challenges affecting health and well-being in the African Region require whole-of- society and whole-of-government action. Less than 50% of the population has access to quality, essential health services.1 Recurring disease outbreaks with high health, economic and social costs; natural disasters and humanitarian crises add pressure on fragile health systems.2 Vulnerable groups are disproportionately impacted by health inequities. 2. Suboptimal health service demand (the regional score is 67 out of 100 percent) affects coverage of essential interventions.3 The health service disruptions during the COVID-19 pandemic reversed progress toward Universal Health Coverage (UHC). A reorientation of national health systems towards primary health care (PHC) is needed as a foundation for UHC and health security.4 3. The Astana declaration on PHC,5 the UHC framework for action6 and the Regional Strategy for Health Security and Emergencies (AFR/RC72/8),7 identified empowering people and communities as a core component of successful implementation. It is critical in increasing health intervention coverage, reducing inequities and improving efficiency, responsiveness, transparency and accountability, and building trust and resilience. 4. A regional strategy for community engagement is proposed to build stronger, equitable and resilient health systems. “Community engagement” is defined as a “process of developing and maintaining relationships that enable stakeholders to work together to address issues and promote well-being. Here the concept of “community” is broadened to capture the continuum of connections and ongoing social interactions throughout the life course. It acknowledges that individuals are part of multiple, interconnected communities that continuously shape identity, choices, and behaviours.8 1 World Health Organization (WHO). 2018. "The state of health in the WHO African Region: an analysis of the status of health, health services and health systems in the context of the Sustainable Development Goals." 2 Inzaule SC, et al. COVID-19 and indirect health implications in Africa: Impact, mitigation measures, and lessons learned for improved disease control. PLoS Medicine. 2021 Jun 23;18(6):e1003666; Ozili P. COVID-19 in Africa: socio- economic impact, policy response and opportunities. International Journal of Sociology and Social Policy. 2020 May 29. 3 WHO. 2018. "The state of health in the WHO African Region: an analysis of the status of health, health services and health systems in the context of the Sustainable Development Goals.". 4 Reorienting health systems to primary health care as a resilient foundation for universal health coverage and preparations for a high-level meeting of the United Nations General Assembly on universal health Coverage (A76/6), Seventy Sixth World Assembly 5 WHO, 2019. Declaration of Astana: Global Conference on Primary Health Care: Astana, Kazakhstan, 25 and 26 October 2018 (No. WHO/HIS/SDS/2018.61). World Health Organization. 6 WHO. UHC in Africa: a framework for action. No. WHO/HSS/HSF/2016.01. World Health Organization, 2016. 7 WHO. Regional strategy for health security and emergencies 2022–2030: report of the Secretariat. 72 (AFR/RC72/8, 2022). World Health Organization. Regional Office for Africa. 8 Evaluation of the WHO Community Engagement Research Initiative, WHO Western Pacific Regional Office, 2023, https://www.who.int/westernpacific/publications-detail/9789290620082. See also: WHO, Voice, agency, empowerment - handbook on social participation for universal health coverage. Geneva: World Health Organization; 2021; WHO Community engagement: a health promotion guide for universal health coverage in the hands of the people. Geneva: World Health Organization; 2020 and WHO. COVID-19 global risk communication and community engagement strategy, December 2020-May 2021: interim guidance, 23 December 2020. World Health Organization; 2020. AFR/RC73/9 Page 2 Regional experience,9 including Ebola virus disease (EVD) outbreak in West Africa10,11 and COVID-19 across the Region12,13 inform the strategy. 5. This strategy strengthens community protection and resilience by outlining how governments can develop and sustain relationships of trust with diverse stakeholders and communities beginning when “all is well” as a foundation for collaboration in crisis times. It includes communities’ participation in PHC, health promotion, and minimizing and mitigating risks and public health events. It provides guidance on leveraging existing service delivery mechanisms and community structures to institutionalize meaningful engagement at the interface of health, development, and humanitarian action. It also prioritizes enhancing research, monitoring, and evaluation and using lessons to inform future interventions. SITUATION ANALYSIS AND JUSTIFICATION Situational analysis 6. The 47 Member States of the African Region are committed to the attainment of UHC. Substantial progress was registered between 2000 and 2019 in increasing health services coverage.14 However, COVID-19 negatively impacted progress due to health service disruptions and changing health-seeking behaviour.15 7. Between 2001-2022, 1843 substantiated public health events were recorded in the Region.16 Zoonotic outbreaks increased by 63% in 2012-2022 compared to 2001-2011.17 COVID-19 public health and social measures (PHSM) severely affected the informal sector, which constitutes 80- 90% of economic activity in sub-Saharan Africa.18 Increased human rights violations, gender-based violence, crime, racism, and marginalization were also reported.19 8. The risk of disease and poor health and well-being is determined by environmental, social, and economic factors. Poverty, poor living and working conditions remain widespread and impact, inter alia, access to clean water, hygiene, and sanitation.20 Unequal access to healthcare means disproportionate public health impacts and failure to achieve UHC.21 The spread of diseases may 9 Recent evidence synthesis highlighted the importance of ongoing community engagement in the Region and elsewhere, including: Adebisi et al. Risk communication and community engagement strategies for COVID-19 in 13 African countries. Health Promotion Perspectives. 2021;11(2):137; Anoko JN, et al. Community engagement for successful COVID-19 pandemic response: 10 lessons from Ebola outbreak responses in Africa. BMJ Global Health 2020; and Frimpong SO, et al. Community engagement in Ebola outbreaks in sub-Saharan Africa and implications for COVID-19 control: A scoping review. International Journal of Infectious Diseases. 2022 Dec 1. 10 Munodawafa D, et al. Monitoring and evaluating the Ebola response effort in two Liberian communities. Journal of community health, 2018, vol. 43, p. 321-327. 11 Ibid. 12 Mwakisha, J, et al. Kenya’s experience: Factors enabling and impeding the COVID-19 response. Health Promotion Practice, 2023. 13 Phori, P, et al. Participatory Monitoring and Evaluation of the COVID-19 Response in the Africa Region. Health Promotion Practice, 2022. 14 WHO/AFRO. Tracking Universal Health Coverage in the WHO Africa Region, 2022 15 WHO. World Health Statistics 2023. Monitoring Health for the SDGs 16 WHO. In Africa, 63% jump in diseases spread from animals to people seen in last decade. 14 July 2022. (Accessed on 12 April 2022) 17 Ibid. 18 Ibid. 19 Ozili P. COVID-19 in Africa: socio-economic impact, policy response and opportunities. International Journal of Sociology and Social Policy. 2020 May 29. 20 Amzat, J, et al 'Social Determinants of Health in Africa', in R. Sooryamoorthy R, Khalema N (eds), The Oxford Handbook of the Sociology of Africa (2022); online edn, Oxford Academic, 18 Aug. 2022. 21 Ibid. AFR/RC73/9 Page 3 be exacerbated by uncontrolled globalization and rapid urbanization, as well as recurring and protracted humanitarian crises.22 9. Such events and conditions expose individuals to social and environmental stressors, affecting health and well-being. In particular, toxic stress has been shown to increase one’s risk for poor health across the life course.23 Intergenerational trauma and exposure to socioeconomic adversity harm mental and physical health.24 10. Community engagement offers an assets-based approach centred on well-being that links lived experience and the multi-level and complex dynamics of health. This has consequences for the practice of medicine, the design, delivery, and integration of health services and the orientation of health care systems. 11. Community health workers (CHW) cadres and programmes can potentially strengthen health and community systems.25 CHWs are strategically placed and have for a long time served to mobilize communities, bring services closer to the people and support emergency response efforts. 12. Past efforts against influenza,26 EVD,27 and the COVID-19 pandemic28 showed that community engagement positively impacted the uptake of PHSM and the prevention of disease transmission. Engaging communities in early warning systems enhanced system efficiency when human and financial resources were limited.29 Overall, community engagement contributes to health systems strengthening and building community resilience.30 Justification 13. Community engagement promotes equity and social justice. Intentionally embedding community engagement processes within health services planning and delivery, supports empowerment and ownership contributing to effective people-centred health promotion and disease prevention.31,32 Aligning engagement practices with pre-existing community structures fosters sustainability, trust-building, and minimizes duplications.33 Unfortunately, community engagement within health systems, PHC, and emergency management planning and implementation remains ad hoc.34 Lack of resources, mistrust, and unaligned priorities pose 22 WHO. WHO emergency appeal: Humanitarian crisis in the Sahel. Geneva: World Health Organization; 2022. 23 Shonkoff J, et al. “The Lifelong Effects of Early Childhood Adversity and Toxic Stress.” Pediatrics. 2012; 129(1). 24 Kivimaki et al. “Association between socioeconomic status and the development of mental and physical health conditions in adulthood: a multi-cohort study.” Lancet Public Health. 2020; 19:30248-8. 25 WHO. Community Health Worker Programmes in the WHO African Region: Evidence and Options — Policy brief. Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO. 26 WHO. Pandemic influenza preparedness and response: a WHO guidance document. World Health Organization; 2009. 27 WHO. WHO community engagement framework for quality, people-centred and resilient health services. Geneva: World Health Organization; 2017 (WHO/HIS/SDS/2017.15). Licence: CC BY-NC-SA 3.0 IGO. 28 Burgess RA, et al. The COVID-19 vaccines rush: participatory community engagement matters more than ever. The Lancet. 2021 Jan 2;397(10268):8-10 29 Sufri S, et al. A systematic review of community engagement (CE) in disaster early warning systems (EWSs). Progress in Disaster Science. 2020 Jan 1;5:100058. 30 Frimpong SO, Paintsil E. Community engagement in Ebola outbreaks in sub-Saharan Africa and implications for COVID-19 control: A scoping review. International Journal of Infectious Diseases. 2022 Dec 1. 31 WHO. Declaration of Astana: Global Conference on Primary Health Care: Astana, Kazakhstan, 25 and 26 October 2018. World Health Organization; 2019. 32 Adebisi YA, Rabe A, et al. Risk communication and community engagement strategies for COVID-19 in 13 African countries. Health Promotion Perspectives. 2021;11(2):137. 33 Ankomah SE, Fusheini A, Ballard C, Kumah E, Gurung G, Derrett S. Patient-public engagement strategies for health system improvement in sub-Saharan Africa: a systematic scoping review. BMC Health Services Research. 2021 Dec; 21:1-6. 34 Anoko JN, et al. Community engagement for successful COVID-19 pandemic response: 10 lessons from Ebola outbreak responses in Africa. BMJ Global Health 2020;4:e003121. doi:10.1136/ bmjgh-2020-003121 AFR/RC73/9 Page 4 challenges.35 Fragmented, suboptimal CHW programmes that lack sustainability have been major drawbacks.36 Successful community engagement processes are not sustained, and lessons are not leveraged effectively.37 14. Empowering people and communities to advocate for responsive and equitable policies, participate in planning and provision of services and adopt healthy behaviours is the foundation of PHC.38 Strengthening mechanisms for community empowerment is a key component of people- centred services that contribute to UHC.39 In addition, community engagement is central to Health Emergency and Preparedness and Response (HEPR)40 and a core capacity in the International Health Regulation41 and the Sendai framework.42 15. This strategy contributes to attaining sustainable development goal 3 to “ensure healthy lives and promote well-being for all ages” through strengthening countries’ capacities to build and sustain functional structures that foster whole-of-society involvement to achieve UHC and health security. It also addresses the Thirteenth General Programme of Work, 2019-2025 aiming to achieve measurable impacts on people’s health and well-being. THE REGIONAL STRATEGY Aim 16. To create an enabling environment for long-term community engagement that strengthens community protection and resilience through empowerment, enhanced health literacy, and active participation in decision-making and the design, implementation, and evaluation of health and development initiatives. 17. Objectives (a) To map and leverage existing community assets structures that could serve as building blocks for engaging communities in PHC, health promotion and health and social service delivery, including emergency management. (b) To institutionalize community engagement and participation, with a view to strengthen PHC, health promotion and health and social service delivery, including emergency management; and (c) To strengthen interdisciplinary country capacities for research, monitoring and evaluation to document lessons from community engagement practices to inform interventions in countries and the Region. 35 Ramsbottom A, O’Brien E, Ciotti L, et al. Enablers and barriers to community engagement in public health emergency preparedness: a literature review. Journal of community health. 2018 Apr;43(2):412-20. 36 Ibid. 37 Adebisi YA, Rabe A, et al. Risk communication and community engagement strategies for COVID-19 in 13 African countries. Health Promotion Perspectives. 2021;11(2):137. 38 Operational framework for primary health care: transforming vision into action. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF), 2020. Licence: CC BY-NC-SA 3.0 IGO. 39 WHO. UHC in Africa: a framework for action. No. WHO/HSS/HSF/2016.01. World Health Organization, 2016. 40 WHO. Community Protection Subsystem: Overview of HEPR activities and items to be costed. Forthcoming (Draft) 41 WHO. International health regulations (2005). World Health Organization; 2008 Dec 15. 42 United Nations Office for Disaster Risk Reduction. Sendai Framework for Disaster Risk Reduction 2015-2030. Geneva: UNDSR; 2015. AFR/RC73/9 Page 5 Targets 18. By 2025, at least 15 Member States and by 2027, at least 25 would have: (a) Community assets and structures mapped to create a knowledge base to inform future actions; (b) Co-developed standard operating procedures and defined guiding principles for incorporating community engagement in PHC, health promotion and health service delivery; (c) Documented, consolidated and applied lessons from past experiences on community engagement in health promotion, service delivery and emergency management. 19. By 2030, at least 37 Member States would have: (a) Community assets and structures mapped to create a knowledge base to inform future actions; (b) Co-developed standard operating procedures and defined guiding principles for incorporating community engagement in PHC, health promotion and health service delivery; (c) Documented, consolidated and applied lessons from past experiences of on community engagement in health promotion, service delivery and emergency management; and (d) Completed assessments of the strategy’s implementation at the country level. Guiding principles and values 20. Community empowerment and protection: Community protection entails community empowerment and building trust between stakeholders that enable the adoption of preventative and promotive health actions and PHSM. Community readiness demands building resilient communities that are prepared and ready to respond to any public health threat. 21. Whole-of-society and whole-of-government: Multistakeholder and multisectoral collaboration, including non-health and private sectors, will improve effectiveness and manage the critical interdependencies across sectors and levels. A whole-of-society approach entails community empowerment where people have a say about their health and well-being. 22. All-hazards approach: Although hazards vary in origin (natural, technological, societal) and impact, similar health system challenges result from them. An all-hazards approach can increase cost-effectiveness and robust responses. 23. Equity and social determinants: The conditions in which people are born, grow, live, work, play, and age determine health and health equity, which can be worsened by discrimination, stereotyping, and prejudice based on sex, gender, age, race, ethnicity, or disability, among others. Addressing equity and social determinants through community engagement will deliver better health outcomes. 24. Governance and accountability: Community engagement and participation supports inclusive governance and the development of responsive health policies and programmes. Actors should be accountable to local populations. Accountability based on people-centredness, transparency, and human rights ensures the rights, dignity, and safety of those affected, particularly vulnerable and marginalized populations. AFR/RC73/9 Page 6 Priority actions and interventions Leveraging community structures 25. Member States should develop or adapt tools map existing community structures, assets and capacities, including community-based workforce, civil society organizations, and private sector actors by strengthening existing data collection tools such as vulnerabilities assessments. 26. Member States should regularly conduct mapping of existing community structures, including the initiatives, capacities, resources, and tools that could be used to perform the essential functions of health promotion, health service delivery, emergency management and build a knowledge base to inform future actions. Priority should be given to conducting national-level mapping and developing a plan for cascading to sub-national levels. 27. Member States should identify and address gaps and challenges to effective community engagement and identify and meet resource needs, including financial, human, technical and logistical. 28. Member States should leverage community-based assets and collaborate with stakeholders.to conduct ongoing capacity building using integrated training packages to raise health literacy, risk perception, and improve access to accurate health information to strengthen community engagement into health promotion, PHC and emergency management. 29. Member States should engage and inform communities through ongoing engagement with existing community structures on public health issues and ensure timely provision of information using appropriate and locally relevant channels. Institutionalization 30. Member States should mainstream community engagement by ensuring health promotion, emergency management, health service provision and disease prevention strategies and plans include explicit standard operating procedures or have guiding principles on how community engagement will be integrated, implemented, and monitored. 31. Member States should adopt co-creation approaches to preventative and promotive health actions and PHSM along with other services and interventions to ensure inclusive, equitable, and context-adapted health systems that is able to prepare, delivery PHC, address and recover from public health events. Additionally, Member States should enable community-based or -led approaches by providing support and resources. 32. Member States should revitalize PHC structures, including community-based surveillance and community workforce. Establish policies for managing, supervising, sustaining and recognizing formal and informal community workers across sectors contributing to promoting health, preventing diseases and addressing and recovering from emergencies, e.g., establishing a certification programme or policies for sustained remuneration. Ensure that capacity building of community health workforce is based on an integrated training packing. 33. Member States should strengthen links between established mechanisms and infrastructure for linking communities with policymakers and decision-makers, e.g. linking community-based surveillance, early warning systems, and communications channels and the relevant sectors who will use information to define policy direction and action at different phases of emergencies. For example, create two-way communication platforms such as call centres and social media channels or strengthen community health boards and committees and community feedback mechanisms. AFR/RC73/9 Page 7 34. Member States should recognize and reinforce existing mechanisms that enable community members to participate in decision making and feedback on the effectiveness of PHC and emergency services and equitable allocation of resources. Ensure that an accessible remedy and redress mechanism is in place to address concerns, complaints, especially when cases of harassment, sexual exploitation, or abuse are reported. 35. Member States should include community representation, especially marginalized and vulnerable groups in efforts to diversify and strengthen multisectoral and multi-stakeholder partnerships and coordination. Research, monitoring, evaluation, and documenting lessons 36. Member States should involve communities in M&E of health interventions, including emergency interventions by including the community in intra and after-action reviews. Co-develop or update M&E systems and tools with multisectoral and multi-stakeholder partners using consensus-building processes. 37. Member States should generate evidence on the social, environmental and behavioural determinants of health and well-being, and to understand the contexts of public health events while harnessing local knowledge and practices.43 38. Member States should generate accessible and high-quality data disaggregated (age, sex, geographic location, social and economic status) public health and health systems and cross-sector data to assess impact on health and wellbeing. Ensure strategic communications to translate knowledge and evidence to inform decision-making and the design of interventions. 39. Member States should ensure capacity within the Ministry of Health to collect, analyse and act on social, environmental and behavioural evidence (e.g., integrating behavioural insights function within the Ministry of Health, identifying or appointing behavioural and social scientists, anthropologists, etc.) and work with academic institutions able to evaluate and analyze community engagement processes. Ensure that these cadres and academic partners can translate and support the Government in using the evidence to inform plans and policies. 40. Member States should promote the sharing of learnings from community-led interventions and community engagement in health promotion and health service delivery, including efforts from different phases of emergencies across local settings (e.g., through cross-learning visits, mentoring systems, and publication of reports). Prioritize documentation of past experiences and build sustainable and easy-to-use systems for capturing ongoing and future work. Governments with support from WHO should facilitate cross-border sharing of best practices and lessons to inform policies and actions at all levels. 43 Data collection and research methods that could be considered include but are not limited to: Knowledge, Attitudes, and Practices (KAP) studies should be used in decision-making and evidence-based interventions. Participatory methods capturing both scientific evidence and traditional or existing knowledge and lived experiences of people, including vulnerable, marginalized, and hard-to-reach groups, should be used to ensure diverse views are captured. Conduct research to capture community engagement best practices. Use well-adapted research and learning methods that capture the effect, the processes that build trust and relationships, and the contextual factors affecting interventions. AFR/RC73/9 Page 8 Roles and responsibilities 41. Member states should: (a) Provide leadership in adapting priority interventions into the local contexts and implementing activities; (b) Provide leadership and governance to establish partnerships, including with community engagement structures; (c) Conduct high-level advocacy and leadership at all levels for integrating community engagement within PHC and other sectors; and (d) Encourage cross-border cooperation and international stakeholder dialogues. 42. WHO and other partners should: (a) Build awareness and advocate for community engagement by developing an evidence-based narrative and foster a common understanding and shared vision for the scope and function of community engagement across all government services within Member States and WHO, with health leading the way. (b) Promote harmonization of PHC, health promotion, health and social service as well as hazard-specific technical guidelines and tools and sensitize stakeholders on their use to support strategy implementation; (c) Based on the experiences of country-level implementation of the strategy, develop a set of generic indicators of community engagement to be proposed for inclusion in routine health service data collection, such as intra and after-action reviews and possibly the joint external evaluation and tool for analysis of risk; (d) Provide technical support to Member States for the adaptation and assessment of the regional strategy and implementation of priority interventions, including cross-border actions; (e) Mobilize partners and donors to support the implementation of the strategy and advocate for an investment case for community engagement in PHC, health promotion and disease prevention; and (f) Promote and support multisectoral and multistakeholder collaboration and ensure accountability to local populations. Resource implications 43. Member States and partners developing, executing, and assessing community engagement in PHC, health promotion and disease prevention require more regular, systematic, and predictable financial and human resources. It is expected that the institutionalization of community engagement as integral to the health system will in the long term ensure predictable funding and capacity investment. To avoid fragmentation and underfunding, Member States should map and better leverage existing sources of community engagement funding and mobilize domestic and external resources. Monitoring and evaluation 44. M&E is crucial to meet the community engagement strategy's objectives and capture the processes that affect design and implementation. Baseline measures will need to be conducted to inform the M&E framework. Implementation will be tracked annually. Key performance indicators will be incorporated in the annual reports for IHR, community engagement framework, and global programme of work. The Regional Director will update the Regional Committee every two years. AFR/RC73/9 Page 9 CONCLUSION 45. Community engagement connects the dots between health system actors, other sectors, and communities, which is critical to reducing the impact of all-hazard emergencies. Learnings from previous outbreaks and health emergencies that put pressure on already fragile health systems show that epidemics start in the community and end in the community. 46. The strategy will support effective community engagement to help build resilient communities and health systems that can mitigate the effects of health and humanitarian emergencies from all hazards. Establishing credible sources of information on underlying causes of all-hazard emergencies and their prevention and making the information accessible as part of community empowerment is important. Promoting the documentation and sharing of experience will ensure that lessons learned can support more effective community engagement and people- centred health systems. Implementing this strategy to promote community protection and resilience will require adequate domestic funding. 47. The Regional Committee is invited to examine and adopt this strategy.