Stakeholder engagement and participation in program development, implementation, assessment, and evaluation has been a public health value for decades, rooted in important empowerment initiatives.1, 2, 3, 4 Stakeholder engagement is an inclusive process of identifying, interacting, and engaging with individuals or organizations that have a vested interest in the program, issue, assessment, or evaluation. The primary goals of stakeholder engagement involve including stakeholders in planning, implementation and decision making. Effective stakeholder engagement includes:
- Fostering/Building relationships with stakeholders who are essential to understanding the context, issues, processes, and solutions required to implement assessment, fostering respectful partnerships and collaboration.
- Setting and managing expectations for stakeholder contributions and for the assessment, defining decision-making and authority.
- Facilitating discussion and gathering input to ensure that approaches and methods are relevant to context and will fit the needs of communities and/or audience.
- Identifying approaches to increase transparency in decision making towards increased accountability.
- Identifying potential risks that could inhibit implementation of activity.
The level and nature of stakeholder engagement should be decided collaboratively, and be reflective of the stakeholders’ goals, priorities, and resources. Stakeholders should be engaged as early as possible and collaborate in the assessment planning and throughout the implementation, analysis, and dissemination processes.
Questions to Consider
Key questions when conducting Stakeholder Engagement for Surveillance System Assessments include:
- Who are the end users of this assessment?
- What is the purpose of engaging with stakeholders for the assessment process?
- What are the power dynamics among the stakeholders and what are their positions with regard to the assessment and efforts to strengthen or optimize the surveillance system (supportive, opposed, or neutral)?
- Who needs to be consulted or involved in implementing a surveillance system assessment and why?
- Who is being excluded and is this justified?
- What approach will you use for stakeholder engagement?
- Who do you need to include to advocate for resources to conduct the assessment?
- What are the relative levels of influence (power) and interest in the assessment of each stakeholder group?
Common Approaches
Approaches to Stakeholder Engagement for Assessment of Surveillance Systems
The spectrum of stakeholder engagement can be described with varying levels of participation from stakeholders. The levels of participation will depend on many factors including end users, timelines and budgets, surveillance system complexity, and interest/skill levels.
Examples of Stakeholder Engagement Processes
Inform: The Ministry of Health (MOH) has designed a new data collection tool for suspected dengue cases. A district MOH representative meets with clinic staff responsible for collating and reporting monthly data to INFORM them of the new form and explain how to use the tool.
- Advantages: Inexpensive, quick
- Disadvantages: Does not allow for feedback, which can be unempowering and obligatory
Consult: The MOH wants to change the data collection tool for suspected dengue cases. They host a virtual meeting with clinic staff to CONSULT with them about whether this tool would be better than the current form used, potentially reduce the amount of time required to fill form and provide better data to the district. Based on the feedback from clinical staff stakeholders, MOH revises the tool for implementation.
- Advantages: Inexpensive, quick, incorporates opportunity for input
- Disadvantages: Does not allow for formative input into the design process, does not ensure that suggestions will be adopted so can feel performative
Collaborate: The Regional Health Officer (RHO) has asked your team to assess the surveillance system for dengue fever in the region. The RHO team wants to be involved in the design and conduct of the assessment to ensure the right criteria are measured and the results make sense. Therefore, you COLLABORATE with RHO stakeholders to design the assessment. The RHO also gives input on data collection tools but does not have capacity to collect data.
- Advantages: Incorporates expertise from community where surveillance assessment will occur, reflecting context and issues that can directly impact program; can be solution focused because better understanding of need, creates awareness of the program goals for key stakeholders
- Disadvantages: Time consuming, potentially costly
Involve: UW I-TECH is funded to design, develop, implement, and evaluate a public health informatics training program in five countries. UW I-TECH identifies key stakeholders from the public health, epidemiology, and information technology departments within the MOH and academic institutions from participating countries. UW I-TECH hosts a virtual sensitization meeting with identified stakeholders about the programmatic goals and asks stakeholders to identify any additional people to participate in a five-day stakeholder engagement workshop. UW I-TECH hosts a participatory stakeholder workshop to INVOLVE stakeholder to identify and validate competencies for the training program, develop a training model for the fellowship that meets the needs of participating countries, and determine eligibility criteria for participants. The stakeholder group meets again to review curriculum outline and develop projects for training participants. Once the training program launches, stakeholders stay involved to support program activities and training participants.
- Advantages: Incorporates expertise from community where programming will occur, reflecting context and issues that can directly impact program, establishes partnership anchored in communities; creates awareness of the program goals for key stakeholders; meaningful participation; shared decision making
- Disadvantages: Time consuming, potentially costly
Empower: A community at a border city area consisting of two countries wants to understand how to share information more quickly in the event of a dengue outbreak to better protect themselves. Currently, there is no way for community members who live in one country to share news with the community on the other side of a national border. They ask UW I-TECH to help them assess how data flows from one country to another to see if there are approaches to share data more quickly. UW I-TECH presents different options to the community stakeholder group. The group discusses the pros and cons of each approach and decides to conduct a version of community mapping of data flow. UW I-TECH empowers the community stakeholders to develop the process and train those who are going to implement the process; but community stakeholders decide what, when, and how the assessment will be conducted.
- Advantages: Decision-making and ownership of the process is embedded in community leading to increased effective and sustainable outcomes; ensures meaningful participation; capacity strengthening; sustainability of approach
- Disadvantages: Time consuming, expensive, may require specific skillsets to complete activity
Summary Table of Advantages and Disadvantages
| Approach | Advantages | Disadvantages |
|---|---|---|
| Inform | Inexpensive, quick | Does not allow for feedback, which can be unempowering and obligatory |
| Consult | Inexpensive, quick, incorporates opportunity for input | Does not allow for formative input into the design process, does not ensure that suggestions will be adopted so can feel performative |
| Collaborate | Incorporates expertise from community where surveillance assessment will occur, reflecting context and issues that can directly impact program; can be solution focused because better understanding of need, creates awareness of the program goals for key stakeholders | Time consuming, potentially costly |
| Involve | Incorporates expertise from community where programming will occur, reflecting context and issues that can directly impact program, establishes partnership anchored in communities; creates awareness of the program goals for key stakeholders; meaningful participation; shared decision making | Time consuming, potentially costly |
| Empower | Decision-making and ownership of the process is embedded in community leading to increased effective and sustainable outcomes; ensures meaningful participation; capacity strengthening; sustainability of approach | Time consuming, expensive, may require specific skillsets to complete activity |
Key stakeholders in Surveillance Assessments
Who the stakeholders are is defined by the goals of the assessment with consideration of who is conducting the assessment.
National
- Department leads for epidemiology and surveillance in the Ministries of Health, Agriculture, and Environment;
- Policy makers;
- Coalitions representing community groups;
- Multi- and bi-lateral organizations working on public health surveillance and epidemiology;
- Union leadership;
- National organizations working in surveillance and epidemiology;
- Academic institutions;
- Funders
Sub-National
- Regional, provincial epidemiologists, veterinarians, and surveillance leaders and staff
- Municipality leadership; Subnational health and veterinary leadership;
- Community-based organizations;
- Local government;
- Academic institutions;
- Community leaders and members
- Clinic/Hospital leadership;
Considerations When Conducting Stakeholder Engagement
Hierarchy & Group Dynamics: When working with stakeholders, hierarchies can play an important role in stakeholder dynamics. People are less likely to share honest feedback in the presence of supervisors or other authority figures. It is important to consider activities, structures, and norms that create open spaces for participation for everyone during stakeholder engagement.
Positionality: Positionality is the social and political context that comprises your identity. It can be in terms of race, ethnicity, gender, ability, class, and sexuality to name a few. A system of injustice based on past policies, actions, behaviors, and values rooted in colonization and bigotry, often anchored in white supremacy, remains intact in many countries worldwide. Differences in social position and power shape society standards and access. Acknowledging positionality can be important if you are not from the community where you are working. Consider group activities to create connection and trust, including ice breakers, small group activities, watching videos about this topic and group reflection.
Gender Inequity: Gender inequity can contribute to power differentials and affect stakeholder interactions. Assessing gender equity within stakeholder interactions is helpful, creating a plan to improve gender equity wherever deficits are found.
Community Distrust: While disease surveillance is an incredibly powerful tool for safeguarding peoples’ health, the term can be seen as a tool for population control. Further, disease surveillance can be extractive, if an assessment team does not meaningfully engage community members during data collection and share back results. When assessments focus on specific communities, these communities should also be engaged following a participatory stakeholder engagement approach (Collaborate, Inform, Empower).
A highly visible example of this is the sequencing of the Omicron variant of SARS-CoV-2 in South Africa in November 2021, the result of genomic surveillance. This led to the development of the Omicron mRNA booster vaccination, a critical public health countermeasure, but not to vaccine equity for South Africa. Rather than being the first—or even early—beneficiaries of this vaccine, travel bans were placed on South African citizens, and at the time of writing two-thirds of the population has yet to be fully vaccinated.
1 Handbook of Action Research: Participative Inquiry and Practice; 2001:27-37.
2 Lewin K. Action Research and Minority Problems. J Soc Issues. 1946;2:34-46. doi:10.1111/j.1540-4560.1946.tb02295.x.
3 Freire P. Pedagogy of the Oppressed – Ch 1.; 1970
4 Fendall NR. Declaration of Alma-Ata. Lancet. 1978;2:1308. doi:10.1016/S0140-6736(79)90622-6.