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

Nan Chen,David Jacobstein,Joshua Albert,Abigail Mcdaniel,Lilian Otiso,Mallika Raghavan,Richard Kintu,Melissa West

doi:10.9745/ghsp-d-20-00429

Abstract

To develop guidance for governments and partners seeking to scale community health worker programs, we developed a conceptual framework, collected observations from the scale-up efforts of 7 countries, workshopped the framework with technical groups and with country stakeholders, and reviewed literature in the areas of health and policy reform, change management, institutional development, health systems, and advocacy. We observed that successful scale-up is a complex process of institutional reform. Successful scale-up: (1) depends on a carefully choreographed, problem-driven political process; (2) requires that scaled program models are drawn from solutions that are available in a given health system context and aligned with the resources, capabilities, and commitments of key health sector stakeholders; and (3) emerges from iterative cycles of learning and improvement, rather than a single, linear scale-up effort. We identify stages of the reform process associated with each of these 3 findings: problem prioritization, coalition building, solution gathering, design, program readiness, launch, governance, and management and learning. The resulting Community Health Systems Reform Cycle can be used by government, donors, and nongovernmental partners to prioritize and design community health worker scale-up efforts, diagnose challenges or gaps in successful scale-up and integration, and coordinate the contributions of diverse stakeholders.

Highlights

The world today faces a daunting global health crisis; despite decades of medical and technological progress, half the world’s population[1] remains without access to primary health care (PHC) services.Community health workers (CHWs) are essential to realizing strong PHC that is[2]: accessible, equitable, safe, of high quality, comprehensive, efficient, acceptable, available and affordable, and will deliver continuous, integrated services that are people-centred and gender-sensitive.CHWs can extend access to health services, save lives,[3] and generate strong returns on investment.[4]
The Community Health Systems Reform Cycle www.ghspjournal.org policy commitments to scale CHW programs remain stuck in implementation challenges or have fallen short on their targets.[6]
Integrating Community Health Program (ICH)-supported partner organizations in each of these countries have worked with their respective ministries of health to scale, strengthen, or sustain community health programs. As part of this collaboration, we present a framework for community health reform, draw on lessons learned from across the 7 countries’ institutionalization efforts, and provide guidance on CHW institutionalization within governmentmanaged health systems (The Supplement contains more details on the framework development)

Summary

Introduction

The world today faces a daunting global health crisis; despite decades of medical and technological progress, half the world’s population[1] remains without access to primary health care (PHC) services.Community health workers (CHWs) are essential to realizing strong PHC that is[2]: accessible, equitable, safe, of high quality, comprehensive, efficient, acceptable, available and affordable, and will deliver continuous, integrated services that are people-centred and gender-sensitive.CHWs can extend access to health services, save lives,[3] and generate strong returns on investment.[4]. The Community Health Systems Reform Cycle www.ghspjournal.org policy commitments to scale CHW programs remain stuck in implementation challenges or have fallen short on their targets.[6] In multiple cases, countries have scaled community health programs only to find that those programs had little effect on access to PHC services or health outcomes such as mortality.[7,8,9] These challenges range from implementation fidelity, governance, management, and financial resources. Recent studies on “exemplars” in community health have started to unpack this “black box.”[11]

Methods

Findings

Conclusion