Abstract
There have been increased calls for low- and middle-income countries to develop community health systems (CHS) policies or strategies. However, emerging global guidance brackets the inherent complexity and contestation of policy development at the country level. This is explored through the case of Zambia’s 5-year Community Health Strategy (CH Strategy), formulated in 2017 and then summarily withdrawn and reissued two years later, with largely similar content. This paper examines the events, actors, and contexts behind this abrupt change in the Strategy, through an analysis of documentary sources and interviews with 21 stakeholders involved in the policy process. We describe an environment of contestation, characterised by numerous international partners weighing in on the CH Strategy, interfacing with shifting loci of responsibility for the CHS in the Ministry of Health (MoH). Despite the rhetoric of participation, providers and communities played no part in the policy process. These dynamics created the conditions for the abrupt change in strategy, illustrating the inherently fraught and political nature of policy development on the CHS in many countries. Going forward, we conclude that paying attention to processes of CHS policy development, and in particular the interaction between events, actors, and contexts, is as important as ensuring meaningful policy content.
Highlights
Community health systems (CHS) are the subject of growing interest based on their potential to leverage different community resources, enhance primary healthcare and advance population well-being in attaining universal health coverage.[1]
This section begins with an outline of the mandated procedures for policy development, followed by how the community health (CH) Strategy was developed
We discuss the repeated attempts by the Ministry of Health (MoH) to grapple with multiple actors and processes in CHS policymaking
Summary
Community health systems (CHS) are the subject of growing interest based on their potential to leverage different community resources, enhance primary healthcare and advance population well-being in attaining universal health coverage.[1]. Despite the growing momentum in support of CHS, community health (CH) programs experience many challenges These include underfunding and the difficulty of bridging the gap between idealized policy and implementation realities,[3] a wide array of community programs involving multiple stakeholders, extensive fragmentation and complex community contexts.[3,7] Fragmentation is partly due to the way programs and initiatives are funded – as vertical and diseasespecific, and partly to the lack of coordination mechanisms.[7] Further, the understanding of the CHS is quite varied within and across countries and in the health systems research fraternity.[8] This understanding ranges from the narrow view of CHS as heavily focused on local community volunteer programs, to broader concepts that encompass all of society’s efforts aimed at improving population wellbeing.[2,8]
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