Inspired by the successes being achieved with the campaign to eradicate smallpox, the World Health Organization (WHO) in the mid 1950s launched the Global Malaria Eradication Campaign. The focus of the campaign was interruption of the malaria parasite's transmission cycle through case detection and treatment as well as vector control, primarily with the use of a newly developed insecticide dicholoro-dephenyl-trichloroethane (DDT) . The eradication initiatives introduced had considerable political and financial support and were launched simultaneously around the world with the exclusion of Africa. Eradication teams were deployed to spray millions of homes, dust forests and fields and drain wetlands in the vicinity of human settlements . The WHO provided financial and technical support to assist countries in preparing comprehensive action plans, training personnel, implementation, monitoring and evaluation, and there was collaboration and coordination with international assistance agencies such as the United Nations Children's Fund (UNICEF), USAID and The Rockefeller Foundation .
As a result, malaria was eliminated from the US, Japan, Korea, Taiwan, Spain, Italy, the Balkans, Greece, northern Africa and parts of the South Pacific . Countries that were successful in becoming malaria free were primarily those who had strong and advanced malaria control programmes prior to the commencement of the global eradication campaign . Nevertheless, in the 1950s and 1960s, significant control was also achieved in countries with a history of meso-, hyper- and holoendemic malaria such as Sri Lanka, India and in the south-west Pacific [3–5].
Despite the promise these successes showed, progress soon began to falter. With the emergence of insecticide-resistant vectors, drug-resistant parasites, technical problems (such as DDT shortages) and due to a number of human behavioural factors, enthusiasm waned and political and financial support dwindled as it became apparent that the global eradication attempt could not succeed . In addition, armed conflict, economic downturns and complex emergencies, caused breakdowns in primary health services, a collapse in malaria control programmes and resurgence of the disease . By 1969 the eradication campaign was abandoned by the WHO and replaced with an endorsement for malaria control .
The limitations of the approach taken by the Global Malaria Eradication Campaign of the 1950's and 60's included assumptions that malaria eradication could be achieved using a one-size-fits-all strategy rather than by tailoring interventions to local contexts and that early successes of the campaign obviated the need for epidemiological and anthropological research . A realisation of these limitations contributed to a shift in focus to a Primary Health Care (PHC) strategy for global health policy as proposed by the WHO and UNICEF at the Alma Ata Conference in 1978 . Primary Health Care was defined by the WHO as, "essential health care made universally accessible to individuals and families in the community by means acceptable to them, through their full participation and at a cost that the community and the country can afford" .
The cornerstone of Primary Health Care is community participation, the popularity of which is premised on the perceived benefits of:
the creation of an enabling environment for public health interventions;
health behaviour modification and reasoned action as a by-product of augmented community empowerment and resilience;
improved efficiency, utilisation and sustainability of health services; and
the harnessing of community capacity and resources to supplement limited allocations for health care .
Community engagement and participation has played a critical role in successful communicable disease control and elimination campaigns in many countries [13–19]. Examples include malaria elimination in Taiwan in the 1960s; the elimination of schistosomiasis in Guangxi Province, China and malaria in Aneityum, Vanuatu in the 1990s; and elimination of onchocerciasis in 2002 in 11 West African Countries [14, 17, 19, 20]. There are lessons to be garnered from current and historic examples of community participation, not least of which is, that the architecture of participation may vary significantly based on influences of factors including geographic location, disease impact, political context, economic conditions, resource availability and health policy.
The benefits of community participation for malaria control and elimination are yet to be fully realized. A study of community participation in 5 African countries in the programmes of the Roll Back Malaria Initiative, found the practical reality of community engagement in malaria control to be still generally low . Possible explanations include; poor understanding of the constructs of participation in developing countries; inadequate health infrastructures and financial resources to support a community participation programme; and differing interpretations of the concept between policy makers, planners and health care professionals [21, 22]. In addition, obtaining community support and enthusiasm for participation in intensified control and elimination activities in the context of disappearing disease, and maintaining it during the pre-elimination and surveillance phases of a programme, will be significantly more challenging than eliciting participation in an endemic or hyper-endemic context .
Defining community participation
Difficulties with designing and implementing community participation programmes have in part been attributed to a lack of consensus on what constitutes 'community' and 'participation' . A number of 'ladders' of participation have been presented in the literature since the late 1960s that theoretically define participation on the basis of the level of power citizens have in decision-making processes, however, a critique of these ladders is beyond the scope of this review [25–29]. Pragmatic geographical definitions of 'community' have dominated tropical disease control to date as they are consistent with the epidemiology of disease transmission, with vector ecology and environmental conditions influencing the vulnerability of people to infection . There are those that suggest this definition of 'community' may be adequate, particularly in rural areas where groups 'living in the same geographical area and sharing the same problems and resources....know one another and have a feeling of togetherness' . However, geographical proximity does not always equate to social cohesiveness and shared interests, particularly where there are imbalances in resource availability, cultural heterogeneity, ethnic tensions, itinerant populations or governance systems that promote individualism [30, 32, 33]. The movement of people as a result of globalization has resulted in a highly dynamic social tissue with decision-making occurring more at the household level rather than the community level, particularly in non-rural settings . Divergence in interests within geographical boundaries can be particularly evident in contemporary urbanized and industrialized settings [30, 35]. The mobilization of collective community action in such settings may be sub-optimal when programmes fail to identify all stakeholders and influential community members and when there exist conflicts of interest, communication difficulties and differing educational needs [33, 36].
Although programmes for communicable disease control and elimination will continue to be targeted geographically based on epidemiological evidence of population vulnerability and intervention effectiveness; it has been suggested that participation of populations may be considerably enhanced by having the recipients of intended interventions define what they perceive as their 'communities' . Accordingly, the development of theoretical concepts and 'etic' (externally derived) definitions of community as the basis of participation should be discouraged . Such pre-defined models may not be relevant at the local level, they can be simplistic and problematic and often do not address the heterogeneity across rural, urban and sub-urban areas or between stable and transient populations [30, 37]. It has been proposed that local 'actors' (including representatives of the poor and marginalized) be facilitated to map the framework, membership and boundaries of what they experience as their 'communities,' whether it be determined by economic, political, cultural, geographic or administrative groupings or through a shared sense of identity based of beliefs or actions [30, 32, 33, 38]
Similarly, it has been advocated that communities be given the opportunity to define their idea of 'participation.' This definition may be influenced by community and stakeholder perceptions of existing and expected levels of participation, community priorities and interests and the acceptability of the implementation of participatory interventions [35, 39]. Consultations with communities to define these concepts in the formative stages of community participation strategy design will be an important first step to generating genuine and sustainable participation to support selective communicable disease control and elimination programmes.
Approaches to community participation
Two conceptually different approaches to community participation have been debated in the literature for decades and in more recent times, this has been moderated by those searching to find the middle ground [22, 40, 41]. To summarize briefly here, the vertical or 'top-down' approach entails centralized development of objectives and action plans for community participation by policy makers and professionals who then endeavour to convince communities to actively participate in their implementation. This approach has merits in terms of logistical efficiency in planning and coordinating implementation of large scale, disease selective, national programmes. It is argued, however, that this paternalistic approach of imposing interventions on communities and convincing them to participate for the greater good will lead to behavioural resistance that can jeopardize health programmes, particularly in an environment where the disease is accorded a low priority in the eyes of the community .
The horizontal or 'bottom-up' approach to community participation seeks to engage and support communities in identifying and prioritizing their own health concerns in order to democratically make decisions regarding resource allocation, which professionals and local authorities are then asked to support . The process of developing individual and community empowerment through this 'bottom-up' approach to participation is valuable for creating positive and sustainable health behaviour change, however, it requires a slow and iterative process and the development of strong, interactive community infrastructures . While this approach is desirable, it often lacks the institutional roots to be able to generate sufficient resources to support each community's objectives . In addition, it is inefficient for rapid national scale-up of programmes and incompatible with selective disease control or elimination agendas, particularly those funded primarily through external donor agencies .
A combined approach has therefore been advocated that aims to reconcile the interim efficiency of a vertical approach required for large scale coordinated planning and implementation, with the longer term goal of a sustainable community driven programme [19, 20, 41, 45]. Discourse regarding approaches to community participation also highlights the importance of considering whether the purpose of participation is either a means to an end (creation of an enabling environment for effective disease control) or as an end in itself (as a path to empowerment and the realization of the PHC philosophy of the right to 'Health for All') [30, 33, 46].
Despite the importance of understanding definitions and approaches to community participation, in order to replicate past successes and to realize its full potential for malaria elimination, a more comprehensive understanding of the constructs of participation is needed. Therefore, the purpose of this paper is to systematically review the evidence and thematically deconstruct case reports of community participation over the past 60 years in order to arrive at an understanding of the architecture of participation for communicable disease control and elimination and provide guidance for the design of community participation strategies for malaria elimination.