Conference Summary & Action Points
Conference Overview
#HealthForAll | ichc2017.org
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by
In
collaboration
with
With
support
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Participation
363 total
participants
44 countries
20 priority EPCMD
countries
22 country
delegations
70% country level
30% global level
Context
» Approaching the 40th anniversary of the Alma Ata Declaration adopted at the 1978 International
Conference on Primary Health Care (PHC); with its goal of “Health for All,” it put PHC and
community-level interventions on the global agenda
» Community engagement, accountability, and resilience are key action areas to accelerate progress
of the Global Strategy for Women’s, Children’s, and Adolescents’ Health
» Mounting evidence for a range of community approaches for health and community-led processes
of planning and implementation, such as women’s groups
» Paradigm shift towards a systems approach for community health
» Political commitment and financing for implementation of effective and sustainable intervention
models at scale are still lacking in many countries
» ICHC provided a forum to bring together stakeholders from multiple sectors to frame, debate,
and build commitment for community health systems strengthening (evidence, scale, and
sustainability in primary health care)
ICHC Areas of Focus
1. Sharing state-of-the-art lessons and experience
2. Enabling country stakeholders to share progress and identify
solutions to persistent challenges
3. Informing national policies and plans though evidence, success,
and adaptive learning
4. Engaging communities as dynamic resources and agents within
national and local systems
Conference Agenda
Day 1:
• Community Health Systems
• Implementation at Scale
Day 2:
• Sustainable Financing for
Community Health
• Multi-Stakeholder and MultiSectoral Partnerships
Day 3:
• Equity & Accountability
• Research & Innovations
Discussion
to
Action
Day 4: Country Planning
and Learning
Conference Outcomes
» Advanced understanding of the opportunities and challenges for institutionalizing
community health, including community health systems strengthening as an emerging
concept
» Learned from community health programs in diverse contexts with documented
processes and impact on RMNCAH issues
» Strengthened dialogue and collaboration between governments, civil society, private
sector, and other development partners, to achieve results
» Developed country-specific action and learning plans that country delegations will
advance with a broader group of stakeholders at country level over the next year
» Prioritized learning themes within and across countries to inform community health
policies and programs and an emerging global learning agenda for community health
systems
» Agreed on 10 Critical Principles for institutionalizing community health
Knowledge Sharing and Action Planning
#HealthForAll | ichc2017.org
Why community health systems?
• Shift needed from primary focus on service delivery to
systems requirements for sustainability and scale
Setting the Stage:
Community
Health in a
Systems
Perspective
• Community health systems include traditional components
that may not be formally recognized in policies and strategies
• Opportunity to enhance the roles and capacity of
communities and local actors to collaborate in systems as
agents of change
• Opportunity for stronger collaboration at the community
level, between communities and health systems, and among
sectors for joint benefits for health with a focus on
communities to drive social change and address social
determinants of health
Community health from a systems perspective takes into
consideration the interrelationships between:
Setting the Stage:
Community
Health in a
Systems
Perspective
Household level caregivers
Community, community groups, and social institutions
Frontline health workers
Formal primary care systems, including supervision, supply chain,
and the like
• Other government sectors: housing, education, social
development, agriculture, etc.
• Representative local health and political structures
•
•
•
•
Question for reflection: What systems changes are missing or
needed in your country context?
Community empowerment, defined as making people stronger
and more confident to take control of their lives (agency +
changes in the social environment), is essential to building
resilient health systems and achieving the Sustainable
Development Goals
Community
Empowerment
Drives Stronger
Community
Health Systems
Diagram credit: UNICEF
Community roles in health systems
Communities are valued, essential, and empowered
actors of the health system for:
Setting the Stage:
Community
Health in a
Systems
Perspective
• Delivering services
• Providing oversight for health services at all levels
• Improving health literacy and advancing social norms
that promote good health
• Enhancing the accountability of health systems to the
people they serve
• Giving voice to those who are currently voiceless
Strengthening and scaling up community and primary health care
platforms could prevent 77% of preventable maternal, newborn, and
child deaths and stillbirths
2.4 million
Key Evidence for
Community
Interventions
0.8 million
0.9 million
SOURCE: Black RE, Walker N, Laxminarayan R, Temmerman M. Chapter 1: Reproductive, Maternal, Newborn, and Child Health: Key Messages of this
Volume. DCP3 RMNCH 2016.
Community-Based Primary Health Care (CBPHC)
• Encompasses a range of interventions delivered outside facilities
• Common implementation approaches included home visits, participatory
women’s groups, community case management (CCM), and outreach from
peripheral health facilities
Key Evidence for
Community
Interventions
Key findings from the comprehensive review of CBPHC
programs
• Evidence that CBPHC is effective in improving MNCH is extensive
• Evidence that investing in facilities alone will improve MNCH in
geographically defined populations is lacking
• Evidence is strong that CBPHC has a pro-equity effect and that facility use is
inequitable
Selected recommendations
• CBPHC needs to become a more important part of health programs, the
foundation of health systems strengthening, and a priority for health sector
funding.
• A rigorous implementation research agenda is also needed to inform the
effectiveness of packages of interventions under routine conditions at scale
for longer periods of time
Evidence and recommendations for
advancing community health systems
• WHO-led Community Based Practitioner (CBP) Guidelines
Review (ongoing)
Key Evidence for
Community
Interventions
• Effectiveness of CBPHC in Improving Maternal, Neonatal, and
Child Health Outcomes (forthcoming: 8 publications in Journal of
Global Health, June 2017)
• WHO-led mapping of evidence gaps for social, behavioral, and
community engagement interventions for RMNCAH
(forthcoming, 2017)
• Synergies, strengths, and challenges: findings on community
capability from a systematic health systems research literature
review (2016)
• WHO recommendations on health promotion interventions for
maternal and newborn health 2015
Additional evidence reviews
• Community participation in health systems research: a
systematic assessing the state of research, the nature of
interventions involved, and the features of engagement with
communities (2015)
Key Evidence for
Community
Interventions
• Anchoring contextual analysis in health policy and system
research: A narrative review of contextual factors influencing
health committees in low- and middle-income countries (2015)
• Examining the links between community participation and
health outcomes: a review of the literature (2014)
• Community accountability at peripheral health facilities: a
review of the empirical literature and development of a
conceptual framework (2012)
• A systematic review of the literature for evidence on health
facility committees in low- and middle-income countries (2012)
Implementation of community health
policies and strategies
Discussion of community health policy implementation and
persisting policy issues demonstrated that countries are grappling
with similar questions, including:
Implementation
at Scale
• Evolving roles of community volunteers in mature CHW
programs, with urbanization, increasing education of women,
and differing needs in urban vs. rural areas (Nepal)
• The need for coordination/harmonization at both national
and sub-national levels in devolved contexts and quality
standards focusing on functionality of community units to
support rapid scale-up (Kenya)
• Strengthening of community health integration into health
systems and community health harmonization (CHW profile
and roles, standardized retention system, behavior change
communication tools, motivation system, commodities,
equipment, and materials (Madagascar)
)
Critical CHW policy issues
There are critical policy questions and challenges that
countries must ask to rationalize, sustain, and scale up
CHW policies and programs, including:
• Classification and nomenclature
Implementation
at Scale
• Lack of or inconsistent systems support that impedes
full realization of CHW potential to contribute to the
PHC context
• Coordinated planning at the national and sub-national
levels (e.g. motivation of volunteers, financing, etc.)
CHW integration: what does it mean?
• Include CHWs in HRH planning
• Have a budget line/resource
allocation
Implementation
at Scale
Planning
Performance
• Ensure supplies/
equipment
• Effective referral systems
• Regular monitoring & supervision
• Clear/transparent selection system,
involving and responding to needs of
communities
• Curriculum to include scientific
knowledge on basic
preventative and curative
care
Production/ • Adapt contents to
health system needs
Education
Deployment/
Retention
• Community
preparedness
• Regular and sustainable
remuneration package
• Opportunities for career and
professional development
Sources: Bhutta et al., GHWA, 2010; Kok, Dielman, et al., 2015; Campbell & Scott, 2011; Darmstadt, Lee, et al., 2009; Jaskie & Tulenko, 2012;
Zulu et al., 2014; Pallas et al., 2013; McCollum, et al., 2016; Bosch-Capblanch, 2011.
• Defining the optimal population ratio per CHW in line with their
scope of work and geographic coverage is required for
institutionalizing community health systems
Implementation
at Scale
• To achieve adequate coverage, consideration should be given to
models that comprise two “tiers” of community workers – a
formal full-time CHW with requisite qualifications and training
and a “lower” level of part-time/voluntary operatives with fewer
technical tasks and demands
• CHWs and referral systems function best in an environment in
which their roles are well defined and they are seen as the “firstline workers” in a well-articulated system, not “competition” for
facility-based workers
• Determinants of successful referral, include access to facilities not
being impeded by barriers (such as transport, permission from
others, cultural and language differences, etc), use of a written
referral slip, and the quality of referral messaging between the
CHW and the client
Implementation
at Scale
• In a facilitated referral, the CHW counsels the client on the reason
for referral, fills out a written referral slip, records the referral in a
register, and inquires about and addresses any barriers to following
through for the client; the referral is then tracked in the HMIS, and
the CHW receives counter-referral information
• Key factors to consider for scale-up of community engagement and
community capacity development interventions include developing
solid partnerships with existing organizations at multiple levels,
working with influential leaders, and strengthening systems and
organizational capacity
“Communities can and
should participate in the
design of interventions, assure
timely implementation, and
contribute to CHW supervision
and motivation.”
“Community health is
broader than CHW programs
focused on service delivery.”
“Integration of community health
into the national health system
requires political will and is cost effective.”
• Strengthening community health systems can be cost-effective
and is a smart investment in social capital and human
resources, but it is not cheap
Sustainable
Financing
• Financing remains one of the biggest challenges for countries
as they scale up community health and transition from donor
dependency to greater government ownership
• Countries had many questions and comments about private
sector financing models for CHWs; better understanding of
these models and opportunities is needed
• Investing $1 in CHWs can return up to $10 in the long-term
(productivity, insurance, employment). A high return on investment
(ROI) (10:1) can only be achieved in high-performing systems. This
ROI focuses on CHWs and does not include other components of
the community health system and therefore could be higher.
Sustainable
Financing
• Making a case for community health systems will become
increasingly important, and all CHS costing and investment plans
have to be done in full alignment with the total health system and
national strategies as subsets rather than standalones
• More attention is needed on finance levels and mechanisms as well
as effective processes focusing on political advocacy and consensus
building within ministries around “best buys”
• Community health can be included as a priority in Global Financing
Facility (GFF) investment cases, and World Bank country offices can
provide additional support
• Countries expressed the need for MOH capacity-building to
develop costed investment plans for resource advocacy
• There is interest in calculating cost savings from CHW
programs to advocate for funding
Sustainable
Financing
• Tools exist for community health planning and costing that
can help determine the cost of community health packages
in order to:
o
o
o
o
Prepare investment cases
Compare cost-effectiveness of community- vs. facility-based
services
Plan and prioritize services within the likely funding envelope
Prepare detailed budgets
• Multi-stakeholder and multi-sectoral partnerships that are inclusive
and data-driven are essential for achieving effective coverage at scale
in global and national acceleration plans in health and country-led
community health systems strengthening agendas
MultiStakeholder and
Multi-Sectoral
Partnerships
• Partnerships should encompass a range of actors, including
representatives of governments, civil society, local and international
NGOs, academia, professional associations, media, private sector, and
underserved populations themselves, with clearly defined roles to
improve equitable outcomes and promote mutual accountability
• Partnerships should leverage expertise and resources from
communities and partners from other relevant sectors (e.g.
agriculture, education, youth) in a coordinated manner
• Who has a seat at the table and how that is determined requires
attention
• Capacity building of local partners to participate and collaborate is
needed to amplify the voice of communities in policies and systems
• Partnerships are most effective when responding to national
leadership and supporting activities harmonized within national
strategies
• Government stewardship should support dialogue around roles and
coordination of efforts to improve sustainability and scale
MultiStakeholder and
Multi-Sectoral
Partnerships
• New thinking about inclusive partnerships is needed in the SDG era
as countries grapple with decreasing donor resources; governments
will increasingly need to leverage partner (civil society, private sector)
and community expertise and resources to harmonize action and
learning
• Greater emphasis is needed on harmonizing partners at national and
sub-national levels and building evidence for inclusive partnership
models
• Successful models of multi-stakeholder and multi-sector partnerships
shared at the ICHC provide insights for improving delivery, demand,
and accountability in the community health systems context
• Country-level partnerships for community health systems
include BRAC, Living Goods, Aspen Management for Health,
Integrating Community Health, SHOPS, WRA, CORE Polio,
Restless Development, Digital Green/SPRING, and N’Weti
MultiStakeholder and
Multi-Sectoral
Partnerships
• Evidence and scale for partnership models varies, and it is
important to ensure that documentation and learning focusing
on partnerships are included in the learning agenda for
community health systems, with clearly delineated partner roles
and measures of successes as well as “failures”
• A roadmap for partnerships that engages partners, including civil
society and the private sector, at the outset to clarify, harmonize,
and build ownership around roles and contributions is critical
“Sustainability of CHWs cannot be achieved with government
alone. It will require looking at resources within the country to create
partnerships with the private sector.”
“If we want to give voice to local
organizations, we need to build their
capacity and press for their participation.”
“Community
health is costeffective but not
cheap.”
“To achieve universal
health coverage,
community health
systems need to be
strengthened and
should be integrated in
to health plans and
financed as an integral
part of country health
systems.”
• EQUIST is a data-driven tool that helps policymakers and managers
identify equitable strategies to save lives and reduce health inequities,
including partnering with communities to optimize available resources
• Community empowerment is a critical process for improved equity and
accountability
o
Creates environments where the powerless have the opportunity to gain
skills, knowledge, and confidence to make choices about their own lives
• Gender-transformative approaches can lead to:
Equity and
Accountability
o
o
o
o
o
Better community health programming and service provision
Equitable leadership and governance
More effective health promotion and prevention
Empowered communities
Better health outcomes
• Providing opportunities to women for training as CHWs/CHVs and space
to discuss issues together can be emancipating – but social norms that
underpin division of labor at home and gender equality more broadly also
need addressing
• Compensation and incentives (a source of debate among countries for
CHWs in general) may perpetuate gender inequality if not aligned with the
demands of the CHW/volunteer role
• Key principles of social accountability approaches
o
o
o
Equity and
Accountability
Build the capacity of community members to understand their
rights, how to collect data and evidence, and how to organize and
demand action effectively
Address underlying power dynamics
Empower governments to take corrective action
• Country experiences with social accountability approaches
included among others
o
o
o
Citizen use of cameras to show lack of health center commodities
and disrespect from facility staff
Community scorecards
National task force on social accountability to bring together key
stakeholders, including district and national governments, to explore
how social accountability can improve RMNCH services and
outcomes
• Evidence from conflict and fragile settings shows that CHWs can
continue providing services and access displaced and hard-toreach populations
• Approaches to community capacity development include
o
o
o
Research,
Innovations, and
M&E
Focusing primarily on developing the capacity of communities to
work together effectively (e.g., strengthening leadership,
management, governance, resource mobilization, etc.)
Focusing primarily on developing technical knowledge and skills
(e.g., health practices, service delivery, etc.)
A combination of the two approaches to achieve a particular goal
(e.g., reduce maternal and newborn mortality, improve nutritional
status, etc.)
• Countries (e.g., Tanzania) are taking advantage of high coverage
of child immunization to integrate and scale up birth registration
o
Birth registration is a critical piece of information for assessing the
reach of health programming
• Mobile technology is useful for data collection as well as clinical
decision support, supervision, and health promotion
o
Need to work on sustainable, interoperable systems that integrate
into the overall health system
• One comprehensive health information system and budget, including
community health, is needed to avoid fragmentation
• Lack of measuring and reporting what happens at community level
impedes advocacy for community health
• Community health M&E systems that are sustainable at scale within
country health systems have indicators that:
Research,
Innovations, and
M&E
o
o
Are small in number
Cover service delivery, strength of community platforms, and competencies
needed for sustainably delivering community-based interventions
• Real-time implementation research, monitoring, evaluation, and learning
are needed to identify, sustain, and scale up effective community
interventions with a practical focus on how to:
o
o
Adapt and support proven community interventions to fit context, sustain,
and scale up effective approaches for engaging and empowering
communities in diverse systems
Improve coverage, quality, and equity of community health services at scale
• Implementation research saves money in the long-term, should be
budgeted, and should not substitute for M&E resources
“We need to be realistic about what
paid and volunteer CHWs can
actually physically do and not expect
too much from them, which only leads
to unsustainable and poor quality
programming.”
“More evidence is needed on the
impact and delivery of community
health interventions in
emergencies and fragile settings.”
Example country action and learning plan
Country Planning
and Learning
• Develop a harmonized, government-led implementation
framework for community health
• Develop an investment case for community health systems, clearly
mapping resources and resource gaps
• Develop an advocacy and communication strategy for community
health with a focus on a community health worker strategy
• Finalize key tools for a sustainable program
• Receive approval from the relevant government ministries
• Submit the policy to the cabinet
• Evaluate community health programs at the county level to
determine why some counties have more effective implementation
than others
Countries submitted detailed action and learning plans for the 12
months following the conference that will inform dialogue with
countries post-ICHC
Country-to-country learning
• Many dimensions to community-level programs
o
Country Planning
and Learning
Individual countries may be well advanced along one
dimension, yet have considerable work remaining to do along
another dimension
• Enabled country delegations to approach other country
delegations to learn from their successes
o
Uganda and Rwanda teams met to exchange lessons learned
with their respective systems
• Allowed sharing of experiences and lessons among countries
that normally have only limited contact
o
o
Among English-, French-, and Portuguese-speaking African
countries
Among Africa, Asia, and the Caribbean
Illustrative knowledge gaps from evidence
reviews to inform learning agendas
Country Planning
and Learning
• Lack of evidence of comprehensive CBPHC at scale for
longer period of time (5 or more years)
• CHW roles and performance; cost-effectiveness of CHWs;
adaptation of lessons from low-and middle-income countries
to high-income countries
• Cross-cutting enabling factors for CHWs (education,
accreditation and regulation, management and supervision,
effective linkage to professional cadres, motivation and
remuneration, and provision of essential drugs and
commodities)
• How to ensure the sustainability of CHW programs through
national planning, governance, legal, and financial mechanisms
Illustrative knowledge gaps from evidence
reviews to inform learning agendas (cont.)
Country Planning
and Learning
• Effective indicators of community health system interface
• Community participation and its role in holding services
accountable
• Sustainability, cost, and scale of community participation
• Gender dynamics in community participation
• Measuring changes in community capacity and links to
health outcomes
• Community participation and its role in holding services
accountable
• Evidence gap map review and prioritized research agenda
forthcoming from a WHO-led process focusing on social
and behavioral and community-engagement interventions
“We will review the existing CHW strategy to align
it with lessons learned from ICHC and ensure it
takes a community health systems approach.”
“This country commits to maintaining the
country delegation to serve as advisory group
on community health to the MOH.”
“With a view to strong community involvement in achieving the
Sustainable Development Goals, this country is committed to an
integrated community health system with strong leadership.”
Extending the Reach of the Conference
#HealthForAll | ichc2017.org
Communications and Knowledge Management
• Expanded the reach of the conference via online engagement
• Leveraged the partnership of co-hosts, collaborators, and potential
•
•
•
sponsors and their various communications platforms
Targeted media engagement at local levels to further communicate
the importance of community health issues discussed
Captured the knowledge and learning from the conference to make
available on the conference website
Building on post-ICHC conferences and meetings to further elevate
conference outcomes and the importance of community health
Website
Blog Series
• http://www.ichc2017.org/
• Find conference resources, including
livestreamed videos, blogs,
presentations, the conference
program, and social media links
• 27 blogs
• 16 organization represented
• Blogs featured on The Huffington
Post, ICHC website, and MCSP’s
website
Livestream
Social Media
• 10 sessions (25 hours)
livestreamed
• Over 500 views and 15,000
minutes watched
• Viewed in 35 countries with
viewing parties in 7 countries
• Reach: 3,415,599
• Impressions: 9,432,785
• Tweets: 1,631
• Contributors: 636
• #HealthForAll trended on Twitter
Looking Forward  
• Community of practice for those
working in community health to
continue the conversation
• Implementation of country action
plans
• Dissemination of the conference
principles (presentation, short
version, long version)
• Present and discuss results at
upcoming conferences
#HealthForAll
ichc2017.org
Additional Slides for Reference
Community Health Systems Defined
»
“A community health system is a set of local actors, relationships, and processes
engaged in producing, advocating for, and supporting health in communities and
households outside of, but existing in relationship to, formal health structures.”
» The local actors in this system who engage in health action include some or all of the
following (context specific):
o
o
o
o
o
Household level caregivers
The array of formal, volunteer, and informal health providers working in communities
Organizational intermediaries: nongovernmental organizations and other forms (religious,
sport, youth, etc.) of associational life; workplaces
Other government sectors: housing, education, social development, etc.
Representative local health and political structures”
USAID Community Health System Framework
Link to
Framework
Here!
The Community Health System Strengthening Model
Example of a model for
community health system
strengthening