Tropical Health Matters

Albino Bobogare and Makiva Tuni shared their community participation experiences at the APMEN Community Engagement meeting in Chiang Mai, Thailand. Care Smith-Guyeye helped prepare this summary of their presentation

Solomon Islands is a country in the West Pacific, neighboring Papua New Guinea and Vanuatu. The country is known for its rugged environment and remote populations, where boats are used as the main transportation across many islands. Farming and fishing are the main means of subsistence. Healthy Island Settings approach is the main priority in the Ministry of Health and Medical Services 2011 to 2015 strategic plan.

Ysabel Province has approximately 200 villages with slightly more than 20,000 total inhabitants. This province has a malaria elimination goal. The community engagement in Ysabel is supported by three pillars: First, a history of tradition and community participation at the local level, whereby populations respect the “chiefly culture.” Second, the Anglican Church through their women’s groups (Mother’s Union) plays a strong role – 95% of the population follows this religion. Last, the provincial government through the provincial health services, the VDCP, health promotion division, Rotarians Against Malaria (RAM), and the Pacific Malaria Initiative Support Center (PacMISC) support community engagement efforts. In addition, engagement of youths is important.

The main activities of the community engagement strategy are school and health facility supervisory visits, village and community visits, Church groups (Mother’s Unions), RAM tool program, and the ‘Tidy Village’ competition. Provincial health school visits are conducted by a provincial public health team lead by a Health Promotion officer with close support from the VBDCP to travel and provide education, and a teacher training booklet and other relevant materials were developed and used.

Health village visits are also conducted and have a syllabus and IEC materials, integrated health committees, ownership of community is considered strong in this province. The Tidy Village competition is based on criteria of health and sanitation. Awards are given for the winners of the competition.

Funding has primarily originated from RAM, Ministry of Health and Global Fund funding with some support from PacMISC, AusAID.

These activities have led to a sustained implementation of source reduction for malaria control and other public health related diseases, and in building political advocacy and expectations of leaders. Challenges to these methods include the lack of supervisory visits because of lack of staff. Plans for the future are to adopt these activities in other provinces and continue and expand the educational component beyond school settings.

Do we take the community seriously – not just as recipients of information? Susanna Hausmann-Muela of the Swiuss Tropical institute raised this important question at the start of her talk to participants at the Asia Pacific Malaria Elimination Network’s Community Engagement for Malaria Elimination Workshop on Tuesday. She stressed the importance of dialogue and mutual learning so that we may learn from the community how they perceive malaria and understand their response to it.  Their response likely reflects the many troubles in people’s lives – trying to access food, jobs, education – and malaria may be the straw that breaks the camel’s back.

We need to learn from people what kind of bednets are ‘right’ for them and not assume that synthetic fiber long lasting insecticide treated net that has survived scientific efficacy trials is the one size that fits all.  At the same time we should not abandon scientific rigor, because randomized control trials of community participation have shown the effectiveness of community participation in reducing neonatal mortality and dengue serological indices in communities. We need similar evidence for malaria interventions. Such interventions though, need to be designed with and by the community bearing in mind APMEN’s community participation framework.

Jeffery Smith of the World-Wide Antimalarial Resistance Network based in the Mekong Region encouraged workshop attendees to learn from the long history of participation by communities and people living with AIDS who took charge of their situation when science alone was not enough to solve the problems of the epidemic.

He encouraged the group to think more broadly about the term community, especially in today’s climate of high mobility, migration and air travel.  Communities everywhere, not just those that physically border endemic countries, need to be vigilant and incorporate malaria surveillance activities into other primary health care programs.

Choosing an appropriate mix of community intervention tools was the theme of the talk by Bill Brieger of the Johns Hopkins University.  He provided examples of how local settlements in partnership with front-line health facilities use a community directed interventions (CDI) approach to increase access and coverage of malaria interventions and other basic health services. Community systems and health systems must collaborate.

A major challenge of CDI is not the willingness and ability for communities to plan and deliver nets, IPTp, RDTs and ACTs at the local level, but in helping health workers and program managers overcome their biases against lay people and ensure that they maintain the supply chain so the community has the commodities needed to provide life saving services at the grassroots.

The APMEN Community Engagement for Malaria Elimination Workshop today provided the ten participating countries opportunities to share and learn from each other. One approach was a round table session or World Café where visitors to each country table could learn about innovative strategies for community engagement and offer suggestions and ideas.  The second format was an exhibition where countries presented materials they had developed for BCC, training and program management.

Below are some of the lessons learned which were posted, discussed and sorted after the roundtable session. Some of these lessons are general for community engagement while others are especially relevant to the malaria elimination phase.

Countries found that interest malaria may wane in the community as experience fewer and fewer cases.  Therefore it was suggested that malaria activities be fully integrated into other community level disease control activities so the community will not ‘forget’ malaria.  Funding may also wane, and community engagement can be the basis for advocacy efforts to also keep health systems engaged in malaria work. Another aspect of integration is the need for community case management capacity for treating other febrile illnesses since the community will perceive and still be concerned about ‘fever’ even in the absence of malaria.

A lesson of general value include the need to build on community achievements. Communities have their own participation ‘culture’. Therefore communities have their own mechanisms for solving problems, and these can be used as a foundation to address new issues like malaria elimination. Ultimately we need to look toward the community for innovative ways to tackle the problem of malaria elimination on their own terms.  Another aspect of the participatory culture in a community may be seasonality based on the variying demands on community members’ time at different times of the year.

We will present some of the individual country experiences in subsequent postings.

The APMEN Community Engagement for Malaria Elimination Workshop started by establishing the broader context of community participation in disease control efforts.  Dr. Wichal Satimal, Director of Vector-borne Disease Control in the Thailand Ministry of Health first welcomed the Asia Pacific Malaria Elimination Network members  to Chiang Mai and Thailand, host country of the Workshop.

Dr Charles Delacollette of WHO reminded participants that community engagement is not new to the World Health Organization and member states, and in fact was the foundation of the 1978 Alma Ata Declaration on Primary Health Care.  Reaching back farther, Dr Delacollette recalled that the malaria eradication effort begun in the 1950s was possibly the first international disease control program to reach out to the remotest communities.  He explained that these foundations today manifest in hundreds of thousands of community health workers and volunteers based in villages throughout the Asia Pacific Region.  Other trends in health system reform include decentralization that can give more power to consideration of local priorities.

Dr. Maxine Whittaker of the University of Queensland, and one of the workshop organizers, stressed that a key theme of this meeting is “bringing the human back into malaria control and intervention.” She drew attention to the fact that at the heart of the six WHO key health systems elements should be a seventh, the ‘people’ who must be partners in strengthening health systems.

Jo-An Atkinson, also of the University of Queensland reviewed the 60-year history of community participation in disease control and elimination.  An important lesson was the need for better documentation of evidence of what works in terms of community engagement strategies, especially in terms of impact on diseases. Jo-An outlined a variety of factors that influence a community’s ability and willingness to engage in disease control activities ranging from gender and power relationships to lack of congruence between community perceived priorities and agency targets.

Ultimately the challenge to participants posed during this first session was the need to begin the process of establishing best practice guidelines for community engagement in malaria elimination before the end of the meeting.