Community Health Systems Strengthening

With a shortage of 7.2 million healthcare workers worldwide, the global health system lacks the manpower necessary to optimally treat the world’s population. This is particularly felt by communities who face long travel and poor access to formal health facilities. A strong community-level health system will increase access to care and can improve health outcomes. Community level provision of health care is often approached from a singular intervention view rather than from a holistic and systematic approach that encompasses the full range of health services and support required for successful service delivery at this level. Advancing Partners and Communities (APC) aims to identify the structures required for community-based services and support systems needed for community health workers and community members. Through APC’s community health systems strengthening work, ministries of health, NGOs, and donors may be better positioned to implement more effective and streamlined approaches to community-level service delivery.

Photo credit: Jane Silcock/USAID

Below are select resources related to key issues within community health systems strengthening.

Men’s Engagement in Family Planning

Increasingly, family planning programs understand the need to foster male partners’ active and supportive roles in planning their families. Family planning is often seen as solely a woman’s concern, and yet many women do not have the power to access and use contraception without the permission, cooperation, or support of their spouses or family members. Moreover, norms of masculinity in many areas place a high value on men’s virility and ability to father children and discourage health-seeking behaviors of men, which can be perceived as a sign of weakness.

Men’s roles in family planning may range from open communication and shared decision-making with their female partners about ideal family size and family planning methods, to financial support for accessing family planning, to men’s own uptake of vasectomy and condom use. Efforts to encourage men to become involved in planning their families can also lead to overall improvements in couples’ communication.

Becoming a Model Man
August 2016 | Video

FHI 360, in partnership with Advancing Partners & Communities, implemented Emanzi, a peer intervention program in Uganda, to teach men how to become better husbands and partners. Emanzi, which means role model in the local language, introduces the basic concepts of gender and gender norms, reflects on the injustice of violence against women, encourages positive communication among couples, and reviews the benefits of family planning and HIV testing. More than 850 men ages 18 to 45 have graduated from the program, and an evaluation is under way. Learn more about Emanzi in this presentation given at the 2016 Gender 360 Summit. 

Gender Norms of Health Care Providers

Gender norms are part of the community and affect everyone. Community health programs must recognize that everyone, including program designers and healthcare providers themselves, are socialized into certain ways of thinking and behaving as women and men, and about women and men. As a result, women and men often experience stigma and discrimination from healthcare providers. Healthcare providers should receive training in gender sensitivity to challenge their thinking about gender norms and be mindful of gender issues when interacting with clients.

Female Community Health Volunteer National Survey Report 2014
January 2016 | Report

The 2014 Female Community Health Volunteer (FCHV) survey provides a comprehensive assessment of the FCHV program in Nepal. The document reports the findings of a national-level quantitative survey of FCHVs and from complementary qualitative interviews with key national, district level, and community stakeholders. The results are intended to increase understanding of the current status of the FCHV program and reflect on stakeholder perceptions of program experience and performance.

Community Health Worker Motivation

In the face of global health worker shortages, the use of community health workers (CHWs) is an important health care delivery strategy for underserved populations. In Uganda, community-based programs often use volunteer CHWs to extend services, including family planning, in rural areas. This study examined factors related to CHW motivation and level of activity in three family planning programs in Uganda.

Community Health Policy Matters
May 2017 | Video

APC’s Community Health Policy Matters video tells the story of fictional characters Winnie and Mary, and how a fragmented health system affects each woman’s ability to access family planning services in her respective community. This animated video highlights how policy can improve the health system for women.

Sierra Leone National Community Health Worker Policy 2016-2020
February 2017 | Policy

Advancing Partners & Communities has provided training, technical assistance, and operational support for revising and implementing the MOHS’ CHW Policy. The policy is now a cornerstone of the Presidential Recovery Plan. 

Support to the Policy and Regulatory Framework for Improving Community Health Systems in Sierra Leone
October 2016 | Summary

Advancing Partners & Communities has been an active partner in the Community Health Workers (CHWs) policy revision process, offering ongoing technical assistance to the Ministry of Health and Sanitation (MOHS) of Sierra Leone.

Expanding global impact through Community Health Workers: progress and challenges in counting CHWs
March 2016 | Webinar

On March 2, 2016, World Vision, Frontline Health Workers Coalition & One Million CHWs Campaign hosted a webinar: Expanding global impact through Community Health Workers: progress and challenges in counting CHWs. The webinar presented key findings and discussed the relevance of the journey “from fragmentation to harmonization” for the CHW community at large.

Nepal’s Community-based Health System Model: Structure, Strategies, and Learning
January 2016 | Brief

The Community-based Health System Model briefs identify and discuss critical health system inputs and processes that have contributed to the implementation and expansion of community-based service delivery in different countries. Countries were selected for their geographic diversity, type of service delivery model, and programmatic scale-up. This brief reviews Nepal’s community health model to inform future policy, program design, and implementation in other countries.

Drug Shops

Until recently, the practice of utilizing drug shops to increase access to injectable contraceptives had not received sufficient attention in the literature. This new APC brief discusses the promising strategy. The U.S. Agency for International Development (USAID) has also developed a high-impact practice brief on family planning provision through both drug shops and pharmacies.

Delivery of Injectable Contraception by Drug Shop Operators in Uganda: Research and Recommendations
October 2016 | Brief

At the London Family Planning Summit in 2012, the Government of Uganda committed to providing universal access to family planning and reducing unmet need for family planning from the current 40 percent to 10 percent by 2022. To meet this ambitious goal, all potential means of increasing accessibility to family planning must be explored.

CHSS

Community Health Systems Catalog Country Profile: Zambia
August 2017 | Country Profile

The Zambia country profile provides an overview of the community health system in Zambia according to the most up-to-date policies available.

Endline Infographic: Improving Community Health Services in the Post-Ebola Context
June 2017 | Infographic

This infographic summarizes APC's work in strengthening critical health services in local communities in Sierra Leone, with focus on reproductive, maternal, newborn, and child health.

Technical Brief: Rebuilding Trust in Health Services: Engaging Communities through Facility Management Committees
June 2017 | Brief

This Technical Brief provides detailed information on APC's community engagement work through facility management committees under the Post-Ebola Rebuilding Health Services project in Sierra Leone.

District Summary: Western Area Urban
June 2017 | Summary

This District Summary provides detailed information on the work performed by APC in Western Area Urban District under the Post-Ebola Rebuilding Health Services project.

Strengthening Health Services as Part of the Post-Ebola Transition in Sierra Leone: Community Engagement Implementation Toolkit
April 2017 | Toolkit

The purpose of this toolkit is to guide the community engagement process for improved community ownership of peripheral health unit quality and catchment area health outcomes in support of the project’s Community Engagement Implementation Strategy.

Life After Ebola: Mothers Return to Health Facilities in Sierra Leone
April 2017 | Photo Gallery

After the Ebola epidemic, a community health center in Sierra Leone is now able to provide improved quality health care services, including family planning.

Post-Ebola Recovery: Strengthening Community Health Services Baseline Facility Assessment Report
April 2017 | Assessment

This baseline facility assessment was conducted to better understand the capacity and infrastructure of the health posts in the five priority districts of Sierra Leone, and to establish a benchmark against which improvements made throughout the course of APC's work can be measured.

Community Health Policy Matters
April 2017 | Video

APC’s Community Health Policy Matters video tells the story of fictional characters Winnie and Mary, and how a fragmented health system affects each woman’s ability to access family planning services in her respective community. This animated video highlights how policy can improve the health system for women.

Community Health Policy Matters

Community Health Policy Matters from Advancing Partners & Communities on Vimeo.

Community Health Systems Catalog: 2017 Updates
April 2017 | Publication

APC’s Community Health Systems Catalog documents policy guidance across 25 countries in detailed profiles and data sets.

Understanding the Challenges of Delivering Community Maternal and Child Health Services in a Post-Ebola Context
October 2016 | Infographic

Following the Ebola epidemic, Sierra Leone faces challenges to rebuilding its community health system. This infographic helps explain the challenges of delivering community maternal and child health services in a post-Ebola context.

Program Overview: Sierra Leone, Liberia & Guinea
October 2016 | Publication

The Ebola Transmission Prevention and Survivor Services Program (ETP & SS) launched in July 2016 and is operating under the umbrella of priorities set by USAID’s Global Health Ebola Team. The program works with ministries of health and nongovernmental organizations in regions of Sierra Leone, Liberia, and Guinea that are most affected by the Ebola outbreak.

Sierra Leone: Community Engagement Implementation Strategy & Toolkit
April 2016 | Strategy

Advancing Partners & Communities has drafted a community engagement strategy for adoption and use by all implementing partners in the project’s five districts. In line with the project’s goal of strengthening health services, the strategy focuses on district- and facility-level interventions and emphasizes the role of community health workers (CHWs). The strategy complements other community-based interventions.

Advancing Partners & Communities, Sierra Leone: Program Overview and Accomplishments
March 2016 | Summary

Advancing Partners & Communities received a grant from USAID’s “Ebola Response and Preparedness” funds authorized by the United States Congress to strengthen critical non-Ebola health services, in Sierra Leone. 

Strengthening Community Health Systems through CHWs and mHealth
January 2015 | Paper

This paper details new learning and next steps from CORE Group’s Fall 2014 Global Health Practitioner Conference. Participants at the conference explored the role of NGOs in strengthening health systems from a primary health care perspective that includes community systems, with a focus on supporting community health workers (CHWs).

Using Measurements of Unmet Need to Inform Program Investments for Health Service Integration
June 2014 | Journal Article

This journal article discusses how Demographic and Health Survey (DHS) data could potentially inform optimal strategies to reach women having unmet need with contraceptive services through integrated service delivery. The analysis has the potential to provide program managers with an evidence-based road map indicating which service-delivery platforms offer the greatest potential to reach the largest number of women with unmet need for contraception.

Frontline Health Workers: Expanding Utilization of Family Planning
May 2014 | Fact Sheet

This fact sheet outlines the crucial role frontline health workers play in increasing contraceptive use in their communities by providing data and using several success stories to illustrate accomplishments.

PMA2014/Ethiopia
March 2014 | Infographic

This infographic is designed to show key family planning indicators and indicators for access, equity, quality, and choice for households in Ethiopia using family planning services from January to March 2014.

Community Health Workers in Low-, Middle-, and High-Income Countries: An Overview of Their History, Recent Evolution, and Current Effectiveness
March 2014 | Journal Article

This journal article discusses how over the past half-century, community health workers (CHWs) have been a growing force for extending health care and improving the health of populations. The review highlights the history of CHW programs around the world and their growing importance in achieving health for all. Note: A subscription is required to read the full article.

Ethiopia meets MDG 4 by cutting Under 5 mortality By Two-Thirds Since 1990
September 2013 | Report

This article reports on the success of meeting Millennium Development Goals with Community Health Worker programs in Ethiopia.

Factors Affecting Availability of Essential Medicines among Community Health Workers in Ethiopia, Malawi, and Rwanda: Solving the Last Mile Puzzle
November 2012 | Journal Article

This journal article focuses on the findings related to three key preconditions of the theory of change and how these were used to inform the design of the community case management supply chain improvement strategy in each country. The three key preconditions include product availability at CHW resupply points, supply chain knowledge and capacity among community health workers and their supervisors, and availability of appropriate transportation.

Below you will find links to resources created by APC and other organizations.

APC Resources

Community Health Systems Catalog Country Profile: Zambia
August 2017 | Country Profile

The Zambia country profile provides an overview of the community health system in Zambia according to the most up-to-date policies available.

Community Health Systems Catalog Country Profile: Uganda
August 2017 | Country Profile

The Uganda country profile provides an overview of the community health system in Uganda according to the most up-to-date policies available.

Community Health Systems Catalog Country Profile: Tanzania
August 2017 | Country Profile

The Tanzania country profile provides an overview of the community health system in Tanzania according to the most up-to-date policies available.

Community Health Systems Catalog Country Profile: South Sudan
August 2017 | Country Profile

The South Sudan country profile provides an overview of the community health system in South Sudan according to the most up-to-date policies available.

Community Health Systems Catalog Country Profile: Sierra Leone
August 2017 | Country Profile

The Sierra Leone country profile provides an overview of the community health system in Sierra Leone according to the most up-to-date policies available.

Community Health Systems Catalog Country Profile: Senegal
August 2017 | Country Profile

The Senegal country profile provides an overview of the community health system in Senegal according to the most up-to-date policies available.

Community Health Systems Catalog Country Profile: Rwanda
August 2017 | Country Profile

The Rwanda country profile provides an overview of the community health system in Rwanda according to the most up-to-date policies available.

Community Health Systems Catalog Country Profile: Philippines
August 2017 | Country Profile

The Philippines country profile provides an overview of the community health system in the Philippines according to the most up-to-date policies available.

Community Health Systems Catalog Country Profile: Pakistan (Punjab)
August 2017 | Country Profile

The Pakistan country profile provides an overview of the community health system in Pakistan, with a focus on Punjab province, according to the most up-to-date policies available.

Community Health Systems Catalog Country Profile: Nigeria
August 2017 | Country Profile

The Nigeria country profile provides an overview of the community health system in Nigeria according to the most up-to-date policies available.

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El Instituto Nacional de la Salud (INSALUD) is a public health organization in the Dominican Republic. It was created in 1978 as one of the Managing Bodies of the Social Security; charge of the management and administration of health services Social Security System.

The National Academy of Sciences (NAS) is a U.S.-based, non-profit organization whose members serve as advisors to the nation on issues related to science, technology, engineering, and medicine. The society is comprised of peer-elected scientists regarded for their distinguished contributions to research. NAS members actively contribute to the scientific community domestically and abroad. Over 500 NAS members have won Nobel Prices, and the Proceedings of the National Academy of Sciences journal is internationally recognized.

Columbia University is an American private Ivy League research university located in New York City, New York. It is the oldest institution of higher learning in the state of New York and the fifth oldest in the United States.

World Vision is a Christian relief and development organization that focuses its efforts on emergency relief, education, health care, gender issues, economic development, and child advocacy. World Vision partners with children and families to help them break the cycle of poverty using a community development approach.

October 12, 2017 | Announcement

On September 7-9, 2017, the West African Clinical Research Consortium (WAC), in conjunction with the National Institutes of Health and the Advancing Partners & Communities project, hosted over 150 West African and international scientists, clinicians, researchers, policy makers, and other stakeholders at a conference in Guinea’s capital, Conakry.

October 11, 2017 | Blog

On Aug. 14, Freetown was struck by a mudslide and flash flooding that cost the lives of nearly 500 people. It affected almost 6,000 people living primarily in five of the most hard-hit communities and left hundreds missing.

September 14, 2017 | Blog

Sierra Leone is on its way to a health system that meets the needs of its people and is ready to confront the next infectious disease—be it Ebola or some other virus—with stronger, better-prepared health services.

June 26, 2017 | Announcement

Advancing Partners & Communities held a celebration event on June 20, 2017 in Freetown, Sierra Leone to highlight the achievements of USAID’s largest primary health care investment in Sierra Leone.

JSI, through Advancing Partners & Communities, and the Government of Liberia are providing necessary treatment for Ebola survivors with health problems.

May 02, 2017 | Blog

APC's Ebola Transmission Prevention and Survivor Services program is focusing on meeting the medical and psychosocial needs of Ebola survivors in Liberia.

April 10, 2017 | Announcement

Advancing Partners & Communities held a regional workshop for leadership from Ebola survivor associations from Liberia, Sierra Leone and Guinea in Conakry, Guinea from March 27th to 29th, 2017.

March 27, 2017 to March 30, 2017
| Announcement

Join APC at the Institutionalizing Community Health Conference from March 27, 2017 – March 30, 2017 in Johannesburg, South Africa.

March 08, 2017 | Blog

After the Ebola epidemic, a community health center in Sierra Leone is now able to provide improved quality health care services, including family planning.

February 06, 2017 | Press Release

On February 2, 2017, the Government of Sierra Leone’s Ministry of Health and Sanitation launched the revised Community Health Worker Policy, 2016-2020.

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October 2015 | Video

This video from Measure Evaluation tells a powerful story of how a simple innovation in a paper-based patient tracking system helped improve the health of mothers, newborns, and communities.

Sussex MCHP

One of the biggest challenges throughout the Ebola outbreak in Sierra Leone was a lack of water and sanitation, which led to poor implementation of infection prevention and control (IPC) measures at health facilities. In the post-Ebola context, as the country moves forward with its Health Sector Recovery Plan, water, sanitation, and hygiene (WASH) is a priority.

Bridge built by the community

Post-Ebola, a facility management committee in Sierra Leone is encouraging women to return to health facilities to give birth.

Photo of Zainab

A female community leader in Sierra Leone is able to improve water supply to her community's health facility through advocacy and community engagement. 

Mohamed

Mental health is severely underfunded and under-resourced in Sierra Leone. But these challenges have not stopped Sahr and Mohamed from helping to reduce treatment gaps.

Leah

Leah Mwakinyuke always knew she wanted to be a nurse. She worked hard to overcome barriers to achieve her dream.

Photo of Beatrice

As a peer educator with the HealthKeepers Network (HKN), Beatrice Ghartey receives training in many areas including adolescent reproductive health, sexually transmitted infections, prevention of teenage pregnancy, sexual abstinence and youth friendly services.

Edson

Edson Timothy Mwakanyamale was active in volunteer and administrative economic activities for many years in the Busokelo district before the village elected him to serve as chairperson of the Community Health Fund Users Association (CHFuA) six months ago.

Photo of Fanny

Madam Fanny Stafford is the patron of the Young Peer Educators Club established by the HealthKeepers Network (HKN), a non-governmental organization based in Accra.

Tumpe Mwakasungula

Tumpe Mwakasungula has worked as a nurse midwife for 16 years in the Masukulu community of the Rungwe district and enjoys serving in the community.

Stella Nyarko introducing health products to her clients

Stella Nyarko became a HealthKeeper through a women’s association. She now provides communities with family planning information and health protection products.

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