Community engagement for health system resilience: evidence from Liberia’s Ebola epidemic Kathryn M Barker 1, *, Emilia J Ling 2 , Mosoka Fallah 3,4 , Brian VanDeBogert 5 , Yvonne Kodl 6 , Rose Jallah Macauley 7 , K Viswanath 8 and Margaret E Kruk 9 1 Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, 9500 Gilman Drive, # 0507, San Diego, CA 92093, USA, 2 Department of Medicine, Stanford University School of Medicine, Medical School Office Building, Rm 328, 1265 Welch Rd, Stanford, CA 94305, USA, 3 Community-Based Initiative, United Nations Development Programme and Ministry of Health, 4 A.M. Dogliotti College of Medicine, University of Liberia, P.O Box 10-9020, Capitol Hill, 1000 Monrovia 10, Liberia, 5 Catholic Relief Services, 228 W. Lexington St., Baltimore, MD 21201-3443, USA, 6 International Rescue Committee, 1730 M St NW, Suite 505, Washington, DC 20009, USA, 7 John Snow, Inc., Monrovia, Liberia, 8 Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA and 9 Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA *Corresponding author. Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, 9500 Gilman Drive, # 0507, San Diego, CA 92093, USA. E-mail: katebarker@ucsd.edu Accepted on 12 December 2019 Abstract The importance of community engagement (CE) for health system resilience is established in theor- etical and empirical literature. The practical dimensions of how to operationalize theory and imple- ment its principles have been less explored, especially within low-resource crisis settings. It is there- fore unclear how CE is drawn upon and how, if at all, it facilitates health system resilience in times of health system crises. To address this critical gap, we adapt and apply existing theoretical CE frame- works to analyse qualitative data from 92 in-depth interviews and 16 focus group discussions col- lected with health system stakeholders in Liberia in the aftermath of the 2014–15 Ebola outbreak. Health system stakeholders indicated that CE was a crucial contributing factor in addressing the Ebola epidemic in Liberia. Multiple forms of CE were used during the outbreak; however, only some forms were perceived as meaningful, such as the formation of community-based surveillance teams. To achieve meaningful CE, participants recommended that communities be treated as active partici- pants in—as opposed to passive recipients of—health response efforts and that communication plat- forms for CE be established ahead of a crisis. Participant responses highlight that meaningful CE led to improved communication with and increased trust in health authorities and programming. This facilitated health system response efforts, leading to a fortuitous cycle of increased trust, improved communication and continued meaningful CE—all necessary conditions for health system resilience. This study refines our understanding of CE and demonstrates the ways in which meaningful CE and trust work together in mutually reinforcing and beneficial ways. These findings provide empirical evi- dence on which to base policies and programmes aimed at improving health system resilience in low-resource settings to more effectively respond to health system crises. Keywords: Community participation, framework, health systems, diseases, international health, local government, qualitative research V C The Author(s) 2020. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com 416 Health Policy and Planning, 35, 2020, 416–423 doi: 10.1093/heapol/czz174 Advance Access Publication Date: 10 February 2020 Original Article Downloaded from https://academic.oup.com/heapol/article/35/4/416/5732805 by guest on 12 June 2022