Process mapping the One Health response to a rabies outbreak in the Philippines

BACKGROUND: Zoonotic disease outbreaks are a growing global health concern, highlighting the need for tools to strengthen outbreak responses. Process mapping is a systems thinking approach that allows the complex multilevel, multisectoral network of actors and processes involved in an outbreak response to be clearly visualised and analysed using a One Health lens. We applied process mapping to a rabies outbreak in the previously rabies-free Philippine province of Romblon to demonstrate its utility. METHODS: Key stakeholders were interviewed to inform the development of a provisional map of the actors, processes and challenges involved in the outbreak response. During a facilitated workshop, stakeholders worked in multisectoral, multilevel groups to refine the map and co-develop solutions to the challenges identified. RESULTS: Process mapping revealed multiple challenges within rabies surveillance and outbreak response, particularly relating to case testing, recording and reporting, as well as intersectoral communication, community sensitisation and dog vaccination. Many of these issues were exacerbated by structural factors such as the Philippines' archipelagic geography and decentralised governance of animal and human healthcare delivery. Broader issues linked with rabies' endemic and neglected status were also identified: insufficiently One Health-orientated national guidance on outbreak declaration and response; resource constraints exacerbated by political devolution; and persistent weaknesses in intersectoral coordination and data sharing, compounded by gaps in international guidance on rabies and One Health practice. Suggested solutions that were possible to implement quickly with minimal resources, such as staff training, were undertaken. Recommendations requiring structural change, like enhancing reporting systems, were communicated to the provincial, regional and national government as policy briefs. CONCLUSION: Our research demonstrates the potential value of process mapping for enhancing One Health disease surveillance and outbreak response, strengthening health systems, and improving preparedness. To address the more systemic challenges revealed, outbreak response guidance must be improved, for rabies specifically and within One Health frameworks more generally, and the implications of political devolution on the control of neglected tropical diseases should be explored. These steps will be essential to achieving the global target of zero human deaths from dog-mediated rabies by 2030.