People-centred community health systems: What new ideas/changes are you seeing that are moving us into the future?

The COVID19 pandemic has been the biggest disaster in living memory, on almost any measure.[1] It has had had an impact on the health and wellbeing of all citizens. The pandemic’s indirect impacts have touched the lives of virtually every community on the planet. COVID19 prompted a greater need to go beyond a disease and biosecurity focused approach that fails to address mental, social and ecological conditions that affect risk and vulnerability.

Last year I enrolled into the Basecamp for Health System transformation. I was eager to take a systemic approach to understand the complex challenges.I wanted to have a deeper understanding of the health systems and learn more about people-centred community health systems as the bed rock for community-led actions[2].

Here is what I have learned:

Today, more than ever, we acknowledge the need for ?a system change. A shift is needed from disease-centric to resilience-centric thinking. There is a renewed willingness to invest into people centred community health systems to achieving health resilience.

Evidence indicates that investments into community systems and community-led programming can deliver impact, resilience and sustainability.[3] Strong community systems underpin effective community-led and community-based actions. Yet community systems remain insufficiently acknowledged, prioritized or integrated into national plans.

Investments in community health is often heavily directed to the community health workforce as the panacea to strengthening community health systems. while the evidence demonstrates that strong community health workforce programmes?can serve as a catalyst for enhanced community participation and sustainable community-led?approaches to delivering health services , it is not the only solution. We need to rather invest into the community ecosystem. These include all the actors, infrastructures and services that promote community health, ranging from information and services to emergency preparedness and programmes addressing the determinants of health[4].

Community responses and systems are essential to demanding, shaping, providing and improving health interventions that are people-centred, accessible, cost-effective and accountable.

Here are 3 things we need to consider to unpack the systemic dynamics and overlooked areas of community ?governance/agency that need to be ?considered to establish and sustain people centered community health systems in Africa

1.????We are still paying lip services to community participation

There is growing evidence around the importance of community participation[5] and the key relationship between CHWs and community actors as well as the need to involve communities in working with CHW to deliver health.[6]

CHWs’ supportive relationships with community leaders, members and community groups are important enablers of CHW retention, motivation, performance, and accountability. However, there is pressure from donors to achieve quick results therefore bypassing social processes needed for CHW to play the bridging and intermediary role between communities and health systems.

Governments, donors and stakeholders favor easy to measure interventions versus more intangible social processes and community participation that are key to effective and sustainable health outcomes.

Communities and local actors demand agency but few government have reforms and policies that support the devolution of responsibilities to local groups in health?(i.e policies that mandate inclusion of communities in programme planning).

2.????Rigid funding system and fragmented investments hinder the results we need

We are seeing increasing investments into community health, community participation and CHWs work to deliver health closer to communities. These investments though tend to be fragmented, projectized (vertical funding for specific projects) and primarily directed towards increasing the number and tasks of health workers.

In addition, there has been low and un-sustained investments into social structures at community level (such as community committees) and social processes therefore creating issues of scale, quality and equity of interventions.

We need substantial and time-consuming investments to secure the participation of the community in health programming. Community inclusive and community-led strategies may be more difficult, complex, and require more widespread resources, but there is not one silver bullet to solving the complex challenges of today. The exclusion of community systems and community-led approaches from health systems frameworks leads to insufficient attention to elements that need ex-ante efforts and investments to set community health effectively within systems.

3.????Staffing: CHW cannot do it all

In the past years, we have seen how a failure to include local actors and communities, and to leverage and support local knowledge and capacities, can rapidly lead to overwhelmed government services and systems[7] Involving the communities into the work of health workers and ?working together to respond to locally felt needs have not been widespread.

CHWs are not a panacea for weak health systems, and they require well-structured support from the health system and community structures and actors in order to be fully effective.

We need supportive relationships between community groups, the CHW, and the local health system. Only this can positively affect behaviour change and health service utilization.

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There is a growing coalition of organisations that demand systemic investments and changes. I am part of one of them, the International Federation of Red Cross and Red Cross Societies.

Unless we succeed in translating governments and donors commitments to community participation into sustained funding commitments ?and clear policies that integrate local actors and communities into emergency and health systems we won’t quicken our steps towards integrating community roles into health systems frameworks to achieve health for all

Check out the map at the start of this blog and help me/us discuss, what new ideas/changes are you seeing ?that are moving us into the future we need/want?

I’d love to hear from experts out there

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[1] IFRC World Disasters Report 2022, Trust, Equity and Local Action, Lessons from the COVID-19 pandemic to avert the next global crisis https://www.ifrc.org/document/world-disasters-report-2022

[2] Community systems strengthening’ refers to interventions that support the development and reinforcement of informed, capable, coordinated and sustainable structures, mechanisms, processes and actors through which community members, organizations and groups interact. Technical Brief: Community Systems Strengthening (May 2019) https://www.theglobalfund.org/media/4790/core_communitysystems_technicalbrief_en.pdf USAID Strengthening community health systems 2022 https://www.usaid.gov/global-health/health-systems-innovation/health-systems/strengthening-community-health-systems

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[3] LeBan K. How social capital in community systems strengthens health systems: people, structures, processes. https://coregroup.org/wp-content/uploads/2018/12/Components_of_a_Community_Health_System_final10-12-2011.pdf. Accessed 27 Apr 2021.

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[4] IFRC World Disasters Report 2022

[5] 10 proposals to build a safer world together – Strengthening the Global Architecture for Health Emergency Preparedness, Response and Resilience: draft for consultation https://www.who.int/publications/m/item/10-proposals-to-build-a-safer-world-together---strengthening-the-global-architecture-for-health-emergency-preparedness--response-andresilience--white-paper-for-consultation--june-2022

[6] George AS, Mehra V, Scott K, Sriram V. Community participation in health systems research: a systematic review assessing the state of research, the nature of interventions involved and the features of engagement with communities. PLoS One. 2015;10:e0141091. https://pubmed.ncbi.nlm.nih.gov/26496124/

[7] IFRC World Disasters Report 2022