This article first appeared in Forum, The Edge Malaysia Weekly on February 22, 2021 - February 28, 2021

After one year of fighting Covid-19, we are familiar with terms such as “whole-of-society”, “community empowerment” and “#KitaJagaKita”. These terms are not just feel-good buzzwords or politically convenient rhetoric, but they are founded on solid public health principles of pandemic management and in the overall democratic governance of a country.

We believe that Malaysia can do much better in community participation in the next few years of Covid-19. Therefore, we propose a framework for how communities can meaningfully participate in the pandemic response and apply that framework to the recently announced National Covid-19 Immunization Plan.

Appoint more community leaders

We propose our framework in three parts. First, relevant and adequate numbers of community leaders must be appointed to appropriate cabinet or ministry-level committees or task forces, such as the Covid-19 Vaccine Supply Access Guarantee Committee. Right now, these committees or task forces are mostly staffed by leaders or senior civil servants in the federal government. Anecdotally, even technical experts from outside Putrajaya are not always consulted by these committees or task forces.

It is perhaps understandable or even necessary for a strong central government response in the first few months of a pandemic. In the second and subsequent years of Covid-19, it is crucial that the government consciously and actively engages with external community leaders and technical experts instead of relying solely on internal resources. Top-down paternalism is simply not sustainable in a multi-year pandemic.

There are several ways how these non-governmental individuals (NGIs) and non-governmental organisations (NGOs) can strengthen decision-making in Putrajaya. NGIs and NGOs bring real-world concerns, experience and networks, making decisions more realistic and not issued from an ivory tower. NGIs and NGOs ensure diverse voices are heard, making decisions more inclusive and balanced.

NGIs and NGOs can also play a part in implementing the decisions, which is often a missing link between civil servants in Putrajaya and in the field. A structured participation of NGOs and NGIs could have created robust and acceptable standard operating procedures (SOPs) for Chinese New Year in the first instance, instead of issuing the SOPs twice.

Communities can be active contributors and not passive recipients

Second, there are specific roles that community leaders can play in the implementation of solutions. Naturally, the exact roles depend on the type of service and the mandate and resources provided to community leaders. For example, community leaders can easily help in the communication and education elements, acting as a link from the government to the community.

As another example, community leaders can also act as a feedback mechanism, sending information and concerns from the community to the government. Ideally, community leaders will mobilise resources, fill in small gaps in the community (leaving large gaps to the government) and promote community resilience and cohesion.

We share two real-life stories of community leadership and participation in this pandemic. The first is from Malaysia, where Nur Afia Qistina Zamzuri, a nine-year-old in Seremban, sewed personal protective equipment gowns for frontliners in the early months of the pandemic. This shining example is only one of many in which ordinary Malaysians rose up and led their communities, marshalling a community-grown spirit of #RakyatJagaRakyat.

In another real-life story, Singapore introduced Safe Distancing Ambassadors as early as April 2020. Travel guides, taxi drivers or fresh graduates helped educate other citizens on face masks, handwashing and physical distancing. Ambassadors were paid up to S$2,500 (RM7,614) a month; this is a triple-win situation in which the government achieves outcomes, citizens are educated, and the Ambassadors earn incomes.

To deploy communities, we must first understand them

Third, the government must understand how communities are organised in order to deploy them effectively. Communities are built around common identities (such as retired teachers or faith-based organisations), passions (such as charity or education), or issues such as climate change, poverty or road transport safety). Understanding how communities are organised will help the government get the best from them.

This means the government should engage with communities as equal partners, instead of issuing top-down directives. The government should also allow space for communities to decide how they can best help, instead of providing a one-size-fits-all framework. And, finally, the government should make it easier for communities by finding a balance between enough oversight to ensure no bad behaviour and enough freedom to operate to encourage more citizens to join community activities.

If done right, community participation in a multi-year pandemic will help improve health and non-health outcomes. Regular participation will improve familiarity and trust between government officers and the community. This can ease future dialogues, decisions and implementation. Public health leaders will also benefit if they know which NGO or NGI can be approached to help with public education, translation support for migrant communities, or measures to increase vaccine confidence.

Vaccine confidence

Our proposed theoretical framework can be immediately applied to the National Covid-19 Immunization Plan, which was announced by the Prime Minister on Feb 16.

We propose three specific areas in which community leadership and participation are crucial for a successful vaccination programme: vaccine confidence, community organisation for vaccine logistics and delivery, and long-term training of community health workers.

The first stocks of the Pfizer vaccine will arrive in Malaysia in February. With the first dose being imminent, the government must start its vaccine confidence efforts now. Adequate, accurate and culturally appropriate information must be provided through a clear public communications strategy that works with communities as equal partners.

For example, adequate training for community leaders is a first step towards vaccine confidence. A train-the-trainer format for community leaders must be part of the vaccine communications strategy. That training can be amplified by community leaders to their respective communities. These communities can then educate others who have reasonable questions about the vaccine, using accurate facts from trustworthy sources.

An important psychological insight is that people trust those in their “in-groups” or who share their worldview, moral values or identities. That is one important reason vaccine confidence can work well if led by communities for communities. One model we can build on is the United Nations Foundation’s Verified initiative, which provides the tools for volunteers to disseminate accurate information on the vaccine.

Work with communities 

for vaccine delivery

Other than private sector healthcare, communities can also be organised to support vaccine logistics and delivery for Malaysia’s most massive and most important vaccination programme in history. An example of massive community participation in pandemics is from China, which at its peak mobilised 9,000 additional contact tracers only for Wuhan’s 11 million people. The contact tracers comprised teachers, fresh graduates and university students, who received brief training and the resources to do the job well.

The same principle can be applied to support the vaccine logistics and delivery in Malaysia’s vaccination programme. The 600 vaccination sites may need administrative support (suited for unemployed fresh graduates), on-site translation for indigenous peoples (suited for healthcare delivery NGOs who work with indigenous peoples) or opportunistic education on handwashing and physical distancing (suited for any NGO).

Malaysia’s Covid-19 vaccination programme could be the first time that an entire nation sees healthcare being systematically delivered outside of hospitals and clinics. The community participation in this vaccination programme could be a nation-building exercise that can lead to a longer-term training programme for community health workers (CHWs).

In the long term, build CHWs

CHWs have many other names, such as community health representatives, advisers or ambassadors. They are present in many countries such as India, South Africa and the US. They receive basic training in healthcare, are embedded in communities (not health facilities), and regularly interact with the official public healthcare system.

Depending on their country and training, CHWs fulfil different functions. Some are educators, some supervise the six-month treatment for tuberculosis, and some just accompany a sick patient to the clinic. Sometimes, they are paid by governments or NGOs (like in the US and India) or they may be volunteers.

CHWs are supported by the World Health Organization. WHO’s Workforce 2030 strategy encourages countries to “harness the potential of community-based health workers” to achieve Sustainable Development Goals targets.

Malaysia’s Covid-19 Vaccination Plan can be the starting point of a coherent long-term strategy to build a CHW policy and framework. That framework can be the starting point to recruit, train, incentivise and deploy CHWs across Malaysia. The framework can start with Covid-19 vaccination in the short term, scale up to Covid-19-related activities in the medium term and to the entire spectrum of healthcare in the long term.

CHWs have been proven to reduce overall healthcare costs and improve health outcomes. They can help reduce the strain on Malaysia’s overstretched public healthcare system and increase community participation and resilience in our own healthcare. If deployed correctly, it can increase community trust in the government and reduce health inequality between the urban-rural and rich-poor divides, especially in Sabah and Sarawak.

Governments frequently invoke the concept of community engagement, but in the abstract or tokenistic sense. In actual fact, communities are living and breathing organisms with tremendous resources, resilience and practical real-world knowledge. We have proposed a realistic framework to mobilise the best of communities in a multi-year pandemic. All we need now is political will.

Khor Swee Kheng is a physician specialising in health systems, health policies and global health. Tan Sri Lee Lam Thye is a social activist and Chair of the Alliance for Safe Community.

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