The Community Health Systems Reform Cycle: Strengthening the Integration of Community Health Worker Programs Through an Institutional Reform Perspective

Abstract

Despite strong interest and policy commitments from many countries, models for community-based primary health service delivery have been slow to achieve full scale or deliver quality that matches their potential. n Reform requires a carefully choreographed effort to enroll key stakeholders to support change by spotlighting a locally relevant gap in the existing health system's performance. n Designing and launching community health programs depends heavily on local context and must draw from models that are available within a given health system and that align with the resources, capabilities, and commitments of key stakeholders. n Reform should be viewed as an ongoing adaptive and evolutionary process; learning, governance, and management systems must be designed with this trajectory in mind. Key Implications Ministries of health, development partners, and other reform stakeholders can: n Use the principles in the reform cycle process to identify gaps and priorities for technical work or investment n Examine community health efforts to identify where technical approaches can be complemented by political, institutional, and reform approaches n Critically examine projects that implement termlimited, externally driven interventions and adapt designs to promote sustained, well-integrated community health programs at scale

Strength in Diversity: Integrating Community in Primary Health Care to Advance Universal Health Coverage

“…16 Chen et al describe how the institutional health reform cycle can guide policy makers in identifying gaps and opportunities while coordinating input from multiple stakeholders to extend CHW program coverage. 17 These studies provide additional evidence that the likelihood of achieving the SDGs increases as coverage of underserved populations accessing lifesaving interventions and commodities improves.…”

“…20 Consistent with that accelerating shift, financing is described as a critical bottleneck to achieving maturity and scale in several articles. 15,17,18,21 Saint-Firmin et al analyze the distribution of reported expenditure, efficiency, and geospatial mapping in Mali to inform decision makers in transitioning to a domestically funded CHW program. 22 They demonstrate where efficiencies could be found and targeted geographically to reach underserved communities.…”

“…Several articles, including those already mentioned, [15][16][17] focus on policy change and explore the drivers of policy change in community health which, like any system, are complex at every level from global to regional and national to local. Hussein et al and Healey et al discuss the CHW policy development process in Liberia and Kenya.…”

“…The institutional health reform cycle can guide policy makers in identifying gaps and opportunities, coordinating input from multiple stakeholders, to institutionalize CHW programing. 17 Several articles explore the institutionalization of CHWs in terms of supportive supervision, remuneration, recognition, and referrals. Although the priorities vary across settings (e.g., career concerns, service delivery, and support), formal linkages to the broader health system are consistently important.…”

What are the mechanisms and contexts by which care groups achieve social and behavioural change in low- and middle-income countries? Group motivation findings from a realist synthesis

“…(12) There are different reasons for this, from a lack of political will, no finances to scale up, to ill-fitting health policies and unsuccessful pilot programs. (13) There is a surprising lack of in-depth studies that provide guidance to programme designers or could be used to create evidence-based policies. (14) Little research has been conducted into community motivation as a factor that can significantly influence the sustainability of volunteers.…”