Abstract
Various investments could help countries deliver on the universal health coverage (UHC) goals set by the global community; community health is a pillar of many national strategies towards UHC. Yet despite resource mobilization towards this end, little is known about the potential costs and value of these investments, as well as how evidence on the same would be used in related decisions. This qualitative study was conducted to understand the use of evidence in policy and financing decisions for large-scale community health programmes in low- and middle-income countries. Through key informant interviews with 43 respondents in countries with community health embedded in national UHC strategies (Ethiopia, Kenya, Malawi, Mozambique) and at global institutions, we investigated evidence use in community health financing and policy decision-making, as well as evidentiary needs related to community health data for decision-making. We found that evidence use is limited at all levels, in part due to a perceived lack of high-quality, relevant evidence. This perception stems from two main areas: first, desire for local evidence that reflects the context, and second, much existing economic evidence does not deal with what decision-makers value when it comes to community health systems—i.e. coverage and (to a lesser extent) quality. Beyond the evidence gap, there is limited capacity to assess and use the evidence. Elected officials also face political challenges to disinvestment as well as structural obstacles to evidence use, including the outsized influence of donor priorities. Evaluation data must to speak to decision-maker interests and constraints more directly, alongside financiers of community health providing explicit guidance and support on the role of evidence use in decision-making, empowering national decision-makers. Improved data quality, increased relevance of evidence and capacity for evidence use can drive improved efficiency of financing and evidence-based policymaking.
Highlights
Well-resourced close-to-community (CTC) health workers can deliver high-quality care; there is extensive, robust, project- and trial-based evidence for this across a range of settings and disease areas, as shown in a set of recent reviews of community health programmes (Chou et al, 2017; Freeman et al, 2017; Jennings et al, 2017; Perry et al, 2017; Sacks et al, 2017; Schleiff et al, 2017; Scott et al, 2018)
Through key informant interviews with 43 respondents in countries with community health embedded in national universal health coverage (UHC) strategies (Ethiopia, Kenya, Malawi, Mozambique) and at global institutions, we investigated evidence use in community health financing and policy decision making, 33 as well as evidentiary needs related to community health data for decision making
We focus our study in four countries (Ethiopia, Kenya, Malawi, Mozambique) that have large-scale public sector community health programmes that remain highly dependent on external financing
Summary
Well-resourced close-to-community (CTC) health workers can deliver high-quality care; there is extensive, robust, project- and trial-based evidence for this across a range of settings and disease areas, as shown in a set of recent reviews of community health programmes (Chou et al, 2017; Freeman et al, 2017; Jennings et al, 2017; Perry et al, 2017; Sacks et al, 2017; Schleiff et al, 2017; Scott et al, 2018). Armed with this evidence, extending access to primary healthcare through CTC cadres with an aim of universal health coverage (UHC) has long been used as an approach and lately become a priority in many countries (Wang et al, 2016; Bhutta, 2017; Javanparast et al, 2018). Poor data quality affects measurement across both costs and outcomes (Yourkavitch et al, 2016; Regeru et al, 2020)
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