This policy brief sets out key concepts, principles and practical implications for the citywide inclusive sanitation (CWIS) approach. Rapid urbanization, aging infrastructure, and climate change are exacerbating a sanitation crisis. The focus of most urban sanitation interventions remains incremental expansion of centralized sewer infrastructure; little attention is paid to reaching the poor, long-term service provision, financial viability, or the public system functions required to achieve those outcomes. Meeting SDG targets requires a radical rethink of the urban sanitation sub-sector. CWIS offers this. This paper presents a public services framework, set out by the Gates Foundation, for pursuing equitable, safe and sustained service outcomes, at city scale. It reviews the genesis and evolution of the CWIS framework and shares key principles and policy implications.
Documentation of structured community engagement initiatives and real-time monitoring of community engagement activities during large-scale epidemics is limited. To inform such initiatives, this paper analyses the Community Led Ebola Action (CLEA) approach implemented through the Social Mobilization Action Consortium (SMAC) during the 2014–2016 Ebola epidemic in Sierra Leone. The SMAC initiative consisted of a network of 2466 community mobilisers, >6000 religious leaders and 42 local radio stations across all 14 districts of Sierra Leone. Community mobilisers were active in nearly 70% of all communities across the country using the CLEA approach to facilitate community analysis, trigger collective action planning and maintain community action plans over time. CLEA was complemented by interactive radio programming and intensified religious leader engagement.Community mobilisers trained in the CLEA approach used participatory methods, comprised of an initial community ‘triggering’ event, action plan development and weekly follow-ups to monitor progress on identified action items. Mobilisers collected operational and behavioural data on a weekly basis as part of CLEA. We conducted a retrospective analysis of >50 000 weekly reports from approximately 12 000 communities from December 2014 to September 2015. The data showed that 100% of the communities that were engaged had one or more action plans in place. Out of the 63 110 cumulative action points monitored by community mobilisers, 92% were marked as ‘in-progress’ (85%) or ‘achieved’ (7%) within 9 months. A qualitative examination of action points revealed that the in-progress status was indicative of the long-term sustainability of most action points (eg, continuous monitoring of visitors into the community) versus one-off action items that were marked as achieved (eg, initial installation of handwashing station). Analysis of behavioural outcomes of the intervention indicate an increase over time in the fraction of reported safe burials and fraction of reported cases referred for medical care within 24 hours of symptom onset in the communities that were engaged.Through CLEA, we have demonstrated how large-scale, coordinated community engagement interventions can be achieved and monitored in real-time during future Ebola epidemics and other similar epidemics. The SMAC initiative provides a practical model for the design, implementation and monitoring of community engagement, integration and coordination of community engagement interventions with other health emergency response pillars, and adaptive strategies for large-scale community-based operational data collection.
This article describes the development of standard operating procedures (SOPs) for social mobilization and community engagement (SM/CE) in Sierra Leone during the Ebola outbreak of 2014-2015. It aims to (a) explain the rationale for a standardized approach, (b) describe the methodology used to develop the resulting SOPs, and (c) discuss the implications of the SOPs for future outbreak responses. Mixed methodologies were applied, including analysis of data on Ebola-related knowledge, attitudes, and practices; consultation through a national forum; and a series of workshops with more than 250 participants active in SM/CE in seven districts with recent confirmed cases. Specific challenges, best practices, and operational models were identified in relation to (a) the quality of SM/CE approaches; (b) coordination and operational structures; and (c) integration with Ebola services, including case management, burials, quarantine, and surveillance. This information was synthesized and codified into the SOPs, which include principles, roles, and actions for partners engaging in SM/CE as part of the Ebola response. This experience points to the need for a set of global principles and standards for meaningful SM/CE that can be rapidly adapted as a high-priority response component at the outset of future health and humanitarian crises.
Human behaviour will continue to play an important role as the world grapples with public health threats. In this paper, we draw from the emerging evidence on behaviour adoption during diverse public health emergencies to develop a framework that contextualises behaviour adoption vis-à-vis a combination of top-down, intermediary and bottom-up approaches. Using the COVID-19 pandemic as a case study, we operationalise the contextual framework to demonstrate how these three approaches differ in terms of their implementation, underlying drivers of action, enforcement, reach and uptake. We illustrate how blended strategies that include all three approaches can help accelerate and sustain protective behaviours that will remain important even when safe and effective vaccines become more widely available. As the world grapples with the COVID-19 pandemic and prepares to respond to (re)emerging public health threats, our contextual framework can inform the design, implementation, tracking and evaluation of comprehensive public health and social measures during health emergencies.
points• The Social Mobilization Action Consortium (SMAC) was Sierra Leone's largest coordinated community engagement initiative during the 2014 -2016 Ebola outbreak. It worked in all 14 districts in Sierra Leone across >12,000 communities (approximately 70% of all communities), through 2,466 trained Community Mobilizers, a network of 2,000 mosques and churches, and 42 local radio stations.• We describe SMAC's Theory of Change and utilization of the Community-Led Ebola Action (CLEA) approach. We present an extensive dataset of community engagement and monitoring with a focus on over 50,000 SMAC weekly reports collected by Community Mobilizers between December 2014 and September 2015.• Community engagement and real-time data collection at scale is achievable in the context of a health emergency if adequately structured, managed, coordinated and resourced.• We describe a correlation between systemic community engagement, community action planning and Ebola-safe behaviors at community-level.• The SMAC integrated approach demonstrates the scope of data -including surveillance datathat can be generated directly by communities through structured community engagement interventions implemented at scale during an Ebola outbreak.• We highlight important insights gleaned over time on how to informally integrate social mobilization into community-based surveillance of sick people and deaths.
Non-government organisations (NGOs) have long played a role in delivering sanitation services to communities in Southeast Asia and Pacific countries, particularly in rural areas. In contrast with large scale infrastructure focused initiatives, NGO programs commonly focus on building linkages between technical and social realms. Drawing on the breadth and depth of NGO experiences, there are opportunities for NGOs to play a greater role in the sanitation sector and to work in partnership with other actors including utilities and government agencies to ensure both 'hardware' and 'software' components of sanitation are built in to project design and delivery to maximise community benefits and ensure longer term system sustainability. This paper discusses these issues and considers how the contribution of NGOs to the sanitation sector in developing countries might be enhanced. The paper is based on recent research for the Australian Agency for International Development (AusAID) intended to guide investment in the water and sanitation sectors of Asia and Pacific partner countries, exploring the potential for increased NGO engagement. The paper presents findings of the research concerning NGO roles and approaches, discusses existing NGO activities in the sanitation sector in Vietnam and Timor Leste and identifies strategies for NGOs and for other sector actors including utilities and government agencies to maximise the benefits of NGO engagement in the sanitation sector.
Connecting the different scales of epidemic dynamics, from individuals to communities to nations, remains one of the main challenges of disease modeling. Here, we revisit one of the largest public health efforts deployed against a localized epidemic: the 2014-2016 Ebola Virus Disease (EVD) epidemic in Sierra Leone. We leverage the data collected by the surveillance and contact tracing protocols of the Sierra Leone Ministry of Health and Sanitation, the US Centers for Disease Control and Prevention, and other responding partners to validate a network epidemiology framework connecting the population (incidence), community (local forecasts), and individual (secondary infections) scales of disease transmission. In doing so, we gain a better understanding of what brought the EVD epidemic to an end: Reduction of introduction in new clusters (primary cases), and not reduction in local transmission patterns (secondary infections). We also find that the first 90 days of the epidemic contained enough information to produce probabilistic forecasts of EVD cases; forecasts which we show are confirmed independently by both disease surveillance and contact tracing. Altogether, using data available two months before the start of the international support to the local response, network epidemiology could have inferred heterogeneity in local transmissions, the risk for superspreading events, and probabilistic forecasts of eventual cases per community. We expect that our framework will help connect large data collection efforts with individual behavior, and help reduce uncertainty during health emergencies and emerging epidemics.Infectious diseases are constant yet often unpredictable threats. The 2014-2016 EVD epidemic in West Africa alone took over ten thousand lives and led to aid distributions nearing $10 billion from 70 countries 1 . There were two major contributing factors: (i) local health systems were ill-prepared, with Ebola-affected countries falling at least 90% short of WHO recommendations for numbers of doctors and nurses per capita 2 ; and (ii) the declaration of the Public Health Emergency of International Concern came late: over 4 months after the first international transmission event 3 . This last systemic failure likely reflects the fact that EVD outbreaks, like most emerging outbreaks, are highly unpredictable and variable. Before 2014, recent Ebola outbreaks occurred in the
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