Working with community leaders to address shocks,
increase inclusivity, accountability and trust,
and support health system resilience in Sierra Leone

Partners: College of Medicine and Allied Health Sciences and Institute for Development in Sierra Leone. Queen Margaret University and Liverpool School of Tropical Medicine in UK

The 2020-21 COVID-19 pandemic, like the 2014-16 Ebola Virus Disease (EVD) outbreak before it, highlighted the weakness of the health system in Sierra Leone. However, it also opened up the possibility of reflection on areas for strengthening and improving health system resilience in the longer term. Trust has emerged as a key element that needs to be rebuilt, through better and more active engagement of communities and local community leadership structures. Dialogue at the local level and then the incorporation of communities’ views into COVID-19 responses and public health interventions is essential to promote accountability and trust in a context often characterised by mistrust in the health (and wider) system.

Learning from the EVD outbreak included the importance of proactive and decentralised leadership, active community engagement, and media communication. A recent study conducted in Kono district on the role of traditional local leaders and their communities in designing and implementing COVID-19 response strategies, reported that their inclusion and participation remains ad hoc. Additionally, participation played out along starkly gendered lines, with female leaders not included.

This learning site study aims to provide insights into the current engagement of community leaders (not limited to traditional leaders) in response to health shocks and to test approaches to supporting and improving engagement, in order to develop the resilience capacities of the health system. It adopts an inclusivity and accountability lens, ie includes people traditionally or historically excluded and at the same time shifts responsibility expectations and emphasises being accountable towards communities.

The study follows participatory action research principles and methodologies and makes use of qualitative and participatory data collection and analysis techniques. These include participatory power mapping, meetings/workshops with stakeholders, direct observations, and individual interviews with community leaders, health care workers, community health workers, and community members.

This work builds on our previous work on resilience. This study focuses on some of the resilience elements already identified, the existence of effective and inclusive ‘social networks and collaboration’, ‘dedicated leadership and distributed control’, and ‘inclusive and open governance and decision making’. These link to ‘accountability and trust strengthening mechanisms’, that the study aims to support and reinforce to ensure gender equitable provision of quality healthcare.

Outputs

• Case study: Communities mobilise and take health action in a Sierra Leone learning site
• Watch and read a presentation on this work at HSR2022: watch the video here
• Blog post: Community ownership and participation: Studying health systems governance in Moyamba, Sierra Leone
• Blog post: Community engagement, inclusivity and impact in Moyamba District, Sierra Leone

Image: A focus group discussion with community leaders