Background
Inspired by the successes being achieved with the campaign to eradicate smallpox, the World Health Organization (WHO) in the mid 1950s launched the Global Malaria Eradication Campaign. The focus of the campaign was interruption of the malaria parasite's transmission cycle through case detection and treatment as well as vector control, primarily with the use of a newly developed insecticide dicholoro-dephenyl-trichloroethane (DDT) [
1]. The eradication initiatives introduced had considerable political and financial support and were launched simultaneously around the world with the exclusion of Africa. Eradication teams were deployed to spray millions of homes, dust forests and fields and drain wetlands in the vicinity of human settlements [
1]. The WHO provided financial and technical support to assist countries in preparing comprehensive action plans, training personnel, implementation, monitoring and evaluation, and there was collaboration and coordination with international assistance agencies such as the United Nations Children's Fund (UNICEF), USAID and The Rockefeller Foundation [
2].
As a result, malaria was eliminated from the US, Japan, Korea, Taiwan, Spain, Italy, the Balkans, Greece, northern Africa and parts of the South Pacific [
3]. Countries that were successful in becoming malaria free were primarily those who had strong and advanced malaria control programmes prior to the commencement of the global eradication campaign [
2]. Nevertheless, in the 1950s and 1960s, significant control was also achieved in countries with a history of meso-, hyper- and holoendemic malaria such as Sri Lanka, India and in the south-west Pacific [
3‐
5].
Despite the promise these successes showed, progress soon began to falter. With the emergence of insecticide-resistant vectors, drug-resistant parasites, technical problems (such as DDT shortages) and due to a number of human behavioural factors, enthusiasm waned and political and financial support dwindled as it became apparent that the global eradication attempt could not succeed [
6]. In addition, armed conflict, economic downturns and complex emergencies, caused breakdowns in primary health services, a collapse in malaria control programmes and resurgence of the disease [
7]. By 1969 the eradication campaign was abandoned by the WHO and replaced with an endorsement for malaria control [
8].
The limitations of the approach taken by the Global Malaria Eradication Campaign of the 1950's and 60's included assumptions that malaria eradication could be achieved using a one-size-fits-all strategy rather than by tailoring interventions to local contexts and that early successes of the campaign obviated the need for epidemiological and anthropological research [
9]. A realisation of these limitations contributed to a shift in focus to a Primary Health Care (PHC) strategy for global health policy as proposed by the WHO and UNICEF at the Alma Ata Conference in 1978 [
10]. Primary Health Care was defined by the WHO as, "essential health care made universally accessible to individuals and families in the community by means acceptable to them, through their full participation and at a cost that the community and the country can afford" [
11].
The cornerstone of Primary Health Care is community participation, the popularity of which is premised on the perceived benefits of:
-
the creation of an enabling environment for public health interventions;
-
health behaviour modification and reasoned action as a by-product of augmented community empowerment and resilience;
-
improved efficiency, utilisation and sustainability of health services; and
-
the harnessing of community capacity and resources to supplement limited allocations for health care [
12].
Community engagement and participation has played a critical role in successful communicable disease control and elimination campaigns in many countries [
13‐
19]. Examples include malaria elimination in Taiwan in the 1960s; the elimination of schistosomiasis in Guangxi Province, China and malaria in Aneityum, Vanuatu in the 1990s; and elimination of onchocerciasis in 2002 in 11 West African Countries [
14,
17,
19,
20]. There are lessons to be garnered from current and historic examples of community participation, not least of which is, that the architecture of participation may vary significantly based on influences of factors including geographic location, disease impact, political context, economic conditions, resource availability and health policy.
The benefits of community participation for malaria control and elimination are yet to be fully realized. A study of community participation in 5 African countries in the programmes of the Roll Back Malaria Initiative, found the practical reality of community engagement in malaria control to be still generally low [
21]. Possible explanations include; poor understanding of the constructs of participation in developing countries; inadequate health infrastructures and financial resources to support a community participation programme; and differing interpretations of the concept between policy makers, planners and health care professionals [
21,
22]. In addition, obtaining community support and enthusiasm for participation in intensified control and elimination activities in the context of disappearing disease, and maintaining it during the pre-elimination and surveillance phases of a programme, will be significantly more challenging than eliciting participation in an endemic or hyper-endemic context [
23].
Difficulties with designing and implementing community participation programmes have in part been attributed to a lack of consensus on what constitutes 'community' and 'participation' [
24]. A number of 'ladders' of participation have been presented in the literature since the late 1960s that theoretically define participation on the basis of the level of power citizens have in decision-making processes, however, a critique of these ladders is beyond the scope of this review [
25‐
29]. Pragmatic geographical definitions of 'community' have dominated tropical disease control to date as they are consistent with the epidemiology of disease transmission, with vector ecology and environmental conditions influencing the vulnerability of people to infection [
30]. There are those that suggest this definition of 'community' may be adequate, particularly in rural areas where groups
'living in the same geographical area and sharing the same problems and resources....know one another and have a feeling of togetherness'[
31]. However, geographical proximity does not always equate to social cohesiveness and shared interests, particularly where there are imbalances in resource availability, cultural heterogeneity, ethnic tensions, itinerant populations or governance systems that promote individualism [
30,
32,
33]. The movement of people as a result of globalization has resulted in a highly dynamic social tissue with decision-making occurring more at the household level rather than the community level, particularly in non-rural settings [
34]. Divergence in interests within geographical boundaries can be particularly evident in contemporary urbanized and industrialized settings [
30,
35]. The mobilization of collective community action in such settings may be sub-optimal when programmes fail to identify all stakeholders and influential community members and when there exist conflicts of interest, communication difficulties and differing educational needs [
33,
36].
Although programmes for communicable disease control and elimination will continue to be targeted geographically based on epidemiological evidence of population vulnerability and intervention effectiveness; it has been suggested that participation of populations may be considerably enhanced by having the recipients of intended interventions define what they perceive as their 'communities' [
33]. Accordingly, the development of theoretical concepts and 'etic' (externally derived) definitions of community as the basis of participation should be discouraged [
33]. Such pre-defined models may not be relevant at the local level, they can be simplistic and problematic and often do not address the heterogeneity across rural, urban and sub-urban areas or between stable and transient populations [
30,
37]. It has been proposed that local 'actors' (including representatives of the poor and marginalized) be facilitated to map the framework, membership and boundaries of what they experience as their 'communities,' whether it be determined by economic, political, cultural, geographic or administrative groupings or through a shared sense of identity based of beliefs or actions [
30,
32,
33,
38]
Similarly, it has been advocated that communities be given the opportunity to define their idea of 'participation.' This definition may be influenced by community and stakeholder perceptions of existing and expected levels of participation, community priorities and interests and the acceptability of the implementation of participatory interventions [
35,
39]. Consultations with communities to define these concepts in the formative stages of community participation strategy design will be an important first step to generating genuine and sustainable participation to support selective communicable disease control and elimination programmes.
Two conceptually different approaches to community participation have been debated in the literature for decades and in more recent times, this has been moderated by those searching to find the middle ground [
22,
40,
41]. To summarize briefly here, the vertical or 'top-down' approach entails centralized development of objectives and action plans for community participation by policy makers and professionals who then endeavour to convince communities to actively participate in their implementation. This approach has merits in terms of logistical efficiency in planning and coordinating implementation of large scale, disease selective, national programmes. It is argued, however, that this paternalistic approach of imposing interventions on communities and convincing them to participate for the greater good will lead to behavioural resistance that can jeopardize health programmes, particularly in an environment where the disease is accorded a low priority in the eyes of the community [
42].
The horizontal or 'bottom-up' approach to community participation seeks to engage and support communities in identifying and prioritizing their own health concerns in order to democratically make decisions regarding resource allocation, which professionals and local authorities are then asked to support [
22]. The process of developing individual and community empowerment through this 'bottom-up' approach to participation is valuable for creating positive and sustainable health behaviour change, however, it requires a slow and iterative process and the development of strong, interactive community infrastructures [
43]. While this approach is desirable, it often lacks the institutional roots to be able to generate sufficient resources to support each community's objectives [
31]. In addition, it is inefficient for rapid national scale-up of programmes and incompatible with selective disease control or elimination agendas, particularly those funded primarily through external donor agencies [
44].
A combined approach has therefore been advocated that aims to reconcile the interim efficiency of a vertical approach required for large scale coordinated planning and implementation, with the longer term goal of a sustainable community driven programme [
19,
20,
41,
45]. Discourse regarding approaches to community participation also highlights the importance of considering whether the purpose of participation is either a means to an end (creation of an enabling environment for effective disease control) or as an end in itself (as a path to empowerment and the realization of the PHC philosophy of the right to 'Health for All') [
30,
33,
46].
Despite the importance of understanding definitions and approaches to community participation, in order to replicate past successes and to realize its full potential for malaria elimination, a more comprehensive understanding of the constructs of participation is needed. Therefore, the purpose of this paper is to systematically review the evidence and thematically deconstruct case reports of community participation over the past 60 years in order to arrive at an understanding of the architecture of participation for communicable disease control and elimination and provide guidance for the design of community participation strategies for malaria elimination.
Discussion
The findings of this atypical systematic review with qualitative synthesis of published literature over the last 60 years, has elucidated the complex architecture of community participation for communicable disease control and elimination and provided guidance for planning community participation programmes for malaria elimination. Some limitations, however, do exist. The lack of coherent quantitative studies to support findings of the content analysis is a limitation of this systematic review. It is also possible that not all relevant papers were captured due to the search strategy being restricted to English language papers and published material. Grey literature may contain a number of examples of community participation but were not included in the review due to the lack of comprehensive access to this data source. These limitations may have restricted an exploration of regional patterns in influences on community participation. It is also recognized that the qualitative method used for this analysis is vulnerable the introduction of bias. To minimize this risk a transparent reporting of method and an inductive approach to data synthesis were used which included self and peer reflection processes [
33].
The conclusions of this review are consistent with a review carried out in the 1980s which found that there can be no universal model for effective community participation [
119]. However, this systematic review goes further and identifies multi-level, interacting influences on participation and proposes corresponding considerations for the design of participation programmes to support malaria elimination. This review also suggests that although no single model for community participation is possible, regional models may be possible based on similarities in governance systems or approaches to community participation between countries of the same region. This concept, however, requires further exploration. Considerations of paradigms, definitions and approaches to community participation have provided useful guidance for the design and implementation of participation programmes; however, failures continue to occur as a result of lack of understanding of the breadth of factors that influence participation that have been highlighted by this review, as well as insufficient allocation of funding to build adequate long-term infrastructure for community participation [
22,
38,
39,
99].
Where is the evidence to attract investment in community participation?
Although investment in community participation is usually based on the assumption that such efforts will contribute to reductions of disease transmission; this systematic review has revealed a deficiency in robust evidence to support this claim which may be responsible for the lack of prominence community participation is assigned in programme budgets. Of further concern is the message purported by inadequate community participation budgets; that the use of community assets and the promotion of a community ownership and self-reliance approach will substitute for more comprehensive investment required for large scale community-based activities to support disease elimination programmes.
After 60 years of research and comprehensive discussion regarding the merits of community participation for disease control and elimination, there has been a failure to produce sufficient rigorous evidence of its effectiveness in reducing disease transmission. With examples of effective top-down approaches to disease elimination, and a lack of evidence of the significant public health benefit of community participation, it is difficult to lobby donors and policy makers to make significant long-term investments in the infrastructure required to support the 'people' component of health systems [
39,
120]. Much has been written on the human behavioural factors that influence disease transmission and this paper contributes to the literature on issues that influence community participation. Is it not now time to harness this vast resource, design locally appropriate, inclusive and responsive community participation programmes and carry out empirical research with sufficient epidemiological astuteness to contribute to an evidence base from which to leverage adequate future investment?
Quantitative research investigating the effectiveness of community participation in reducing disease transmission has all but been discounted in the literature. It has been criticized as being too difficult and it is often too complex to differentiate out the confounding effects of variations in social and ecological conditions, intervention strategies, differences in local resource availability and quality of existing health infrastructure [
21,
120]. Due to these perceptions, focus has shifted from evaluating community participation using biological indicators to using behavioural or process indicators and measures of social impact [
33,
66,
120,
121]. While these indicators will provide valuable quality monitoring for community participation programmes, they do not contribute to the empirical evidence required to stimulate significant investment from international donors and in-country policy makers. Until it can prove itself an effective public health intervention, genuine community participation is at risk of remaining on the sidelines of public health policy.
Implications for malaria elimination
Countries that were successful in the malaria eradication campaign of the 1950s primarily had strong health systems and advanced malaria control programmes [
2]. In recognition of this, the current global malaria elimination campaign calls for a health systems strengthening approach to provide an enabling environment for programmes in developing countries [
122]. However, this may be more challenging than anticipated. Globalization and macro-economic reforms that promote free market economies have eroded social cohesion that underpins community spirit and participation. In addition, ensuing health inequalities and an abdication of community responsibility for health care delivery have placed health systems under further pressure to respond to meet service requirements consistent with people's increasing expectations and varying priorities [
102,
110,
123]. The capacity of health systems' in developing countries to effectively respond to these challenges as well as support the demands of competing selective disease elimination programmes can especially limited [
123].
Thirty years after the Alma Ata declaration, international public health thinking has once again returned to a PHC focus to systematically address health inequalities and build more sustainable mechanisms for the delivery of universal health care [
123]. A fundamental feature of the renewed push for a comprehensive PHC approach is the accompanying agenda of reforms it includes to better gear health systems towards support of the PHC approach, scale-efficient systems thinking and increasing multi-sectoral involvement [
123,
124]. It is now understood that, '
every intervention, from the simplest to the most complex, has an effect on the overall system' [
124]. Therefore, despite the well-meaning intentions of the health systems strengthening approach to malaria elimination, continued push for selective disease elimination programmes accompanied with the considerable global enthusiasm and political and financial support they rally, may once again place pressure on health systems to divert from their comprehensive PHC objectives.
Another important challenge of strengthening health systems for malaria elimination is establishing the widespread understanding that people are an intrinsic component of health systems, not just as recipients of health care but as drivers of the system itself [
124,
125]. Past failures to invest adequately in research and infrastructure to create sustainable community participation frameworks is evidence of a lack of understanding of the importance of people in health systems effectiveness. Creation of an enabling environment for malaria elimination should necessarily include the fostering of 'competent communities.' This concept arises from the HIV/AIDs literature which highlights the importance of greater attention to 'community readiness' for programme implementation, where potential obstacles are addressed and social assets mobilised in preparation for optimal uptake of interventions and utilisation of health services [
126‐
128]. Health system effectiveness may be significantly enhanced when communities are primed to derive maximum benefit from programme implementation. This groundwork is often neglected in the push to scale up interventions and meet short-term targets set by external funding agencies.
The scale of community participation required for malaria elimination cannot be achieved with an ad hoc approach to its design and implementation. Rather, large-scale cooperative, collective and sustained action requires an appropriate organizational framework for coordination, credibility and accountability. In the past, health planners have used community participation strategies as a means of navigating programme constraints such as scarce financial and human resources and 'human resistance' to interventions [
92]. Community participation for malaria elimination requires significant investment in people as well as the structure and capacity to support this investment, making the design of an appropriate framework at the outset an important first step [
24]. This review emphasizes the importance of avoiding the creation of additional external structures, local-level participation can be incorporated into existing social, organisational and institutional structures through which health authorities decentralize and support implementation of elimination measures, coordinate multi-sectoral collaboration, exchange epidemiological progress and feedback with communities as well as providing technical and resource support [
33,
64].
Above all, integration of a community participation framework for malaria elimination into the broader PHC strategy will be vital. It will have important and reciprocal benefits of strengthening and maintaining health systems on a course towards achieving health equity, while benefiting from established scale-efficiency and harnessing the ensuing re-engagement and inclusive participation of communities in health care delivery for more effective and sustainable malaria elimination. Despite the application of this analysis to the context of the current global malaria elimination efforts, the results of this systematic review of community participation in communicable disease control and elimination could and should be extended to other diseases of poverty such as HIV/AIDS, TB and neglected diseases. This may harmonize efforts at building competent communities for communicable disease control and optimise health system effectiveness.
This review has comprehensively elucidated the multi-level factors that influence community participation for communicable disease control and elimination, and in doing so, contributes to the understanding of the 'people' component of health systems, an outstanding priority identified by the malERA Consultative Group on Health Systems and Operational Research for malaria eradication [
125].
Conclusions
Constraints in financial resources, human resistance to programmes and the lack of adequate public health infrastructure, particularly in remote regions, were fundamental reasons for failures of vertical health projects and the motive for a shift to community-oriented PHC systems in many countries [
57,
62,
67,
92,
103]. The cornerstone of PHC is community participation, which has played a critical role in successful disease control and elimination campaigns in many countries. Despite this, its benefits for malaria control and elimination are yet to be fully realized. This may be due to a poor understanding of the constructs of participation in developing countries as well as inadequate investment in the 'people' component of health systems including essential infrastructure and resources to support the scale of and coordination of community participation required for malaria elimination. The findings of this review of 60 years of published literature on communicable disease control and elimination draws attention to a deficiency in the evidence base for the effectiveness of community participation from which to lobby for significant long-term investment. In addition, the complexity of multi-level, interacting influences on participation identified in this review, attests to the inability to create a global model for community participation within health systems, however, it emphasizes the importance in community participation having a position in every system. Despite the challenges, community participation remains an essential component of any attempt to eliminate malaria; a disease that unlike small pox, currently has no vaccine, is not easily recognizable without appropriate diagnostic tools and can have latent or persistent human infection[
129]. It is recommended that the application of the results of this systematic review be considered for other diseases of poverty in order to harmonize efforts at building competent communities for communicable disease control and optimise health system effectiveness.
Authors' contributions
Planning for systematic review carried out by JA, MT & AV. All authors contributed to the design of the original coding matrix. The systematic review, data analysis and manuscript drafting was carried by JA with support and contributions from all authors. All authors have read and approved the final manuscript.