Prioritising community-led social mobilisation – Restless Development’s International Director Jamie Bedson reflects on lessons and recommendations from the Ebola outbreak.
The Ebola outbreak in West Africa has reinvigorated the debate about the role of ‘social mobilisation’ and ‘community engagement’, not only in response to devastating disease but a range of other intractable issues affecting Africa and the rest of the developing world. But what do we mean by ‘social mobilisation’? And why are we only learning now that community leadership is important?
Sierra Leone’s communities are the true heroes of the Ebola response. Over the course of 18 months, a huge proportion of the population has made and maintained significant changes to cultural practice and norms. Norms that have been in place for hundreds of years, such as burial practice and traditional healing. The staggering scale of this behaviour change, a result of the patience, commitment, innovation and temerity of communities, has placed community-led social mobilisation at the centre of discussions on lessons from the outbreak.
But has the Ebola outbreak really changed our understanding of social mobilisation? Has this really increased understanding of the agency of communities and how this agency can be supported? Or has it reinforced that ‘community engagement’ is another tool in the development sector’s armoury, a nice add-on the real business of providing health care, food and education? The answer is probably yes to all three questions, depending on who is answering. But regardless of perspective, there are crucial lessons to be drawn on all sides that should improve the way we practice community engagement in the future.
Breaking through the fear
When Ebola first struck Sierra Leone, the initial reaction of everyone in the country – communities, government and the international community – was of fear. ‘Ebola is real’ and ‘Ebola is a killer that can be prevented’ were the primary messages provided to communities; a ‘fear appeal’ often shouted through megaphones by poorly trained volunteers or over the radio. Community members panicked and ran – not only to avoid treatment for Ebola in centres from which they would never return, but also in fear that symptoms that might have been anything from flu, malaria or food poisoning may be Ebola, and a death sentence.
Although Ebola awareness-raising to ensure that people understood ‘Ebola is real’ was an absolute necessity in the early stages of the response, there was little space for two-way conversation between communities and those that knew how to prevent the spread of Ebola. This conversation was vital to address concerns and myths, identify alternative practices and help communities to understand what to do if the reality entered their community. Not touching was just a start – a large proportion of the community were soon not shaking hands, avoiding crowds and strangers – but how could communities organise to protect themselves from Ebola transmission?
A decade of mobilising communities to take action
‘Social mobilisation’ refers to activities where communities are supported and empowered to undertake their own analysis and take their own action. This support might be awareness of and access to services, tools for action, information, participation in decision-making and policy. Often the support comes in the form of community mobilisers – religious leaders, women’s groups, youth leaders, traditional healers, traditional leaders and community health workers – who are in turn often supported (although not always) by government, non-governmental organisations and community organisations. It refers to interventions where communities are aware of and contribute to decisions that affect them and where feedback is provided on the impacts of these decisions. It involves not only communities themselves, but considers the structures within which they exist – be it social, political or economic. Social mobilisation is often based on the understanding that communities, in time, would develop protective responses in response to health threats even if there was no intervention on the part of authorities. Social mobilisation seeks to accelerate this process.
Restless Development has for a decade identified, trained and supported young Sierra Leonean mobilisers to work in rural communities for between eight to eighteen months. In this time we have worked in 50% of all chiefdoms in all districts, across hundreds of communities. Mobilisers work with communities, in schools, clinics and youth centres to find solutions and create demand for services related to sexual and reproductive health, maternal and child health and to encourage participation in civic processes. Core to the programme is the facilitation of linkages between existing structures in communities – for example between and across adults, adolescents and children, schools and teachers, health centres and staff, police and family support units, religious leaders, traditional leadership, and local and district government.
When Ebola arrived in Sierra Leone, Restless Development used this experience of deep community engagement to design the Community-led Ebola Action (CLEA) model with our partners in the Social Mobilisation Action Consortium (SMAC), and drew on our cohort of more than 2,000 ex-volunteers to implement it. We worked in 55% of rural communities across the country for more than a year – 8,634 communities, 49,000 individual community visits by mobilisers. We worked closely with the government, bi-laterals and multi-laterals, international non-government-organisations and community-based organisations, at the local and national level. And we saw communities take a leadership role in reducing Ebola transmission.
Lessons learned (and re-learned) about community-led social mobilisation
It works. Large-scale, structured, flexible, adaptable, integrated, community-led social mobilisation can be achieved and maintained to achieve massive behaviour change. SMAC has been a test case. Proving this is in its preliminary stages, but this time we have the data and we are confident in what it will show.
Communities are usually best placed to identify solutions that work for them – cultural practice can be harmful when disease strikes or for a girl’s sexual health. But they are also the source of positive and reinforcing behaviour.
Social mobilisation and community engagement are often regarded as a ‘soft’ and relatively non-technical add-on to medical interventions. However this is misguided; social mobilisation and health education (demand creation) must be equally prioritised along with service delivery and resourcing (supply).
Community-led social mobilisation approaches are not easy, but are extremely powerful. It is hard to do properly and can be expensive – however, social mobilisation investment is a drop in the ocean compared to medical investment.
Communities must be engaged with interventions at all stages; planning, implementation, decision-making, monitoring and evaluation. Engagement does not stop at the needs assessment and planning stage, nor does it stop after talking to traditional leaders.
There is a need to set standard operating practices of community engagement and social mobilisation. Community engagement can be subject to a technical rigour that ensures quality and accountability. Social mobilisation, done properly, does not require the use of expensive incentives that distort the relationship with communities. Nor does it mean people should work for free, or a t-shirt and pair of gum boots.
Young people have played a significant role across all pillars of the Ebola response in Sierra Leone; they have shown leadership, innovation, high levels of civic responsibility and determination. They can be the leaders of effective social mobilisation.
Based on what we learned, what do we recommend?
Social mobilisation – often considered expensive by governments and funding partners – is a good investment. Compared to the costs of treatment, it is a bargain (2.95% of DFID’s Ebola spending). We can build large networks of social mobilisers or community health workers for a tiny proportion of health spending, and should.
Community engagement should be seen as a fundamental element of disease response and of strengthening health-systems ; development strategy should be designed and funded with community engagement at their centre, not at their periphery.
Standard Operating Procedures for social mobilisation and community engagement should be required for donors and governments for all development interventions, particularly health, nutrition and education.
Use the community-engagement infrastructure and large-scale behaviour change achieved within the context of the Ebola crisis to work with communities to address other issues, such as child marriage, teenage pregnancy and Female Genital Mutilation.
Continue to support governments to develop capacity related to social mobilisation, such as funding health education departments, working to see communities as partners in development.
The organisations best placed to support with social mobilisation are local NGOs and Community-based Organisations. Through longer term relationships and greater outreach with communities they often have an advantage, particularly in rural communities. They should be prioritised for capacity building and funding.
In the affected countries, capitalise on the large pool of youth that have been on the front lines of the Ebola and have had their skills and capacity fast-tracked; make them a focus of targeted programming.
Lessons for development
Placing communities at the centre of development is what we as a sector are supposed to do. But we don’t always do it well – it is difficult and, we are often told, expensive. While in an humanitarian emergency, with the fear of Ebola as a driver, behaviour change may have been easier to achieve. Meanwhile ‘everyday’ development issues in communities – such as teenage pregnancy, child marriage and female genital mutilation – may seem more intractable. However, we are yet prioritise community-led social mobilisation at scale in parallel to traditional development interventions.The Ebola outbreak has demonstrated that this can be done successfully to high impact. It is time to replicate this to tackle longer term issues in the recovery period in Sierra Leone and elsewhere. Communities can be supported to make positive change on these issues, and good community-led social mobilisation will identify and work with these. That is the challenge for all partners during this upcoming recovery period for Sierra Leone, and for all interventions in the future.