5 key questions on close-to-community programmes as part of a broader health systems approach

By Kate Hawkins

On the 26 June the UK Guardian newspaper held an online  Live Question and Answer Session on health systems. Sally Theobald contributed on behalf of REACHOUT with a focus on close-to-community providers of health care. Amref set the scene by stressing that strong health systems:

‘Must reach right down to the community level as demand must exist to feed up into the formal structures…health workers, including community health workers, are a fundamental building block to promote health system strengthening in sub-Saharan Africa.’

This point was echoed by others in the discussion but they also pointed to some of the challenges in rolling out, or maximising on the opportunities afforded by close-to-community programming. Here are 5 key questions on close-to-community programmes as part of a broader health systems approach:

1. Why are community systems important?
Because they are the bedrock of the health system, argued Helen Counihan of the Malaria Consortium:

‘the components of stronger health systems, such as sustainable funding, equitable access to care, a strong and efficient health management system and successful behaviour change communication all depend upon a greater role for communities in the delivery of services, mobilisation of demand and increasing access to those most in need.’

Community systems have the potential to make health services more inclusive and less discriminatory. Ann Noon drew on the work of the International HIV/AIDS Alliance and argued that weaknesses within health systems are, ‘felt particularly acutely by populations most at risk of HIV (or key populations), often marginalised or highly stigmatised groups including men who have sex with men, people who use drugs, sex workers, and transgender people. This underlines the importance of investing in community system strengthening’. Work with these marginalised groups is often hampered by a lack of political will on the part of Governments and therefore community-level organisations and civil society play a key role in expanding health service access and advocating for legal and policy change.

We need to build health systems that can address the social determinants of health and the interplay between poverty and ill-health. Sally Theobald suggested that close-to-community providers – who are embedded in communities – have an important role to play here. They are: uniquely placed to understand the multiple ways in which poverty shapes vulnerability to ill health, care seeking and the impact of ill-health; strategically placed to facilitate community participation and stimulate critical thinking; and they act as a catalyst to social action to address the social and cultural determinants of poor health. However, further training, support and investment in this critical cadre is required for them to realise their full potential.

2. How should we support close-to-community programmes?
JaneCo argued that:

‘investing in health workers is central as they play a number of roles in the system; as recipients of skills and support thereby increasing the capacity in the longer term, delivering better services to patients now and in the future, plus as advocates for change, as informed voters/members of communities. The more we support health workers to fully enact their roles, the more of a ‘voice’ the health system has within the country and the political system.’

Neil Squires felt there was a need to go beyond the traditional health workforce and cited the thinking of a WHO  working group which is building a global Human Resources for Health Strategy. Individuals, communities and non-health professionals could increasingly play a role in improving health. He explained that one of the, ‘biggest challenges to the health system will be to ensure that we think innovatively and beyond the health system, building individual and community self-reliance and resilience for improved health.’

Sara Bennett, from Future Health Systems, suggested that there was no ‘one size fits all’ approach that would be applicable in all settings:

‘Financial, geographic and cultural barriers are interconnected and often interact – compounding access problems for the poorest and most marginalized communities. I think that the entry point for addressing them varies across different contexts: sometimes it means strengthening skills for existing informal health care providers, sometimes developing effective cadres of community health workers. But there is no “magic bullet” approach that should be applied everywhere.’

3. How can we assure sustainability and accountability in close-to-community programmes?
Sarah Ssali from the ReBUILD Consortium, argued that ‘people matter but we need to accompany [community systems] with accountability mechanisms, especially social accountability to ensure that local leaders do not become a class apart and become less accountable to the local communities’. Sally Theobald explained how REACHOUT analysis in Mozambique shows that communities genuinely hold CHWs accountable and work closely with them to support them. Where these models of partnership work well this builds both the strength and responsiveness of health system as well as the resilience of communities.

Building infrastructure, longer timeframes, and exit and integration strategies were considered key to sustainability by Amref:

‘and most importantly there needs to be local ownership and leadership. If someone trains community health workers as part of a project, but doesn’t empower either them or the local Government/health structures on how to work together- thereby providing ongoing support- then the community health worker will almost certainly fade away over time or when the project ends.’

This point was echoed by Helen Counihan who said that:

‘the sustainability and ownership of community-based interventions have been greatly strengthened by engaging the formal health service from the beginning. This was done by building capacity of the peripheral health facility staff as a starting point, and then placing the responsibility of training and ongoing support of community health workers with them.’

4. How do we assess the impact of close to community programmes?
Dina Balabanova (of London School of Hygiene and Tropical Medicine and Good Health at Low Cost) felt that often a ‘blueprint approach’ to health system strengthening does not ‘allow for meaningful engagement with those on the frontline, providers and users. Even where we see good governance initiatives, participation and learning from community stakeholders does not appear to be a priority.’

Much of the debate focused on the indicators that donors, in particular, use to measure the success of health system strengthening interventions in order to understand value for money and demonstrate this to tax payers. Sara Bennett described how:

‘[P]eople working on health systems strengthening do gymnastics to demonstrate how an investment in village health committees contributes, through long complex chains of causality to health impact. Making the link to service delivery outputs (coverage etc.) is easier and preferable in my view. If we really want to go this route then we also need to invest in more impact evaluations – though have to admit that I am uncertain this is always money well spent. At least let’s make sure that such evaluations also provide real time evidence to strengthen implementation and aid decision making.’

Dina Balabanova made the point that:

‘We also need to raise the question of what do we mean by ‘good’ or ‘strong’ evidence? What kind of evidence is acceptable in situations of very limited data, or where no randomised design is possible (e.g. intervention is being rolled out to all)? How do we assess implementation and identify bottlenecks?’

5. How can we work together on community-level health interventions?
Panellists focused on the opportunities afforded by the upcoming Health Systems Global Symposium. Dina Balabanova explained that this year’s theme is the:

‘Science and practice of people-centred health systems, recognising the central role of people as users, creators and stakeholders in effective health systems. Recognising that health systems ultimately exist to respond to need, health seeking preferences and values. Also emphasising that those at the frontline (their views, motivation) are key to system functioning, and health systems should adapt to their needs.’

Sara Bennett described the growing interest in people centred health systems as an international movement and pointed to the WHO’s work putting together a new strategy on people-centred health services. She suggested that, ‘This movement…is responding in part to the growing burden of non-communicable diseases and is talking a lot about the co-production of health, meaning how can we better involve patients and communities in service delivery.’ Sally Theobald highlighted the importance of understanding and sharing knowledge about what works across different contexts. The Health Systems Global Thematic Working Groups offer excellent opportunities for dialogue and experience sharing across and between contexts.

The Health Systems Global Thematic Working Group on Supporting and Strengthening the Role of Community Health Workers in Health System Development is  one such group. If you would like to join and be part of these ongoing discussions contact Faye Moody (n.f.moody@liverpool.ac.uk) to find out more.

Photo courtesy of Photo by Nena Terrell/USAID Ethiopia